Provider Demographics
NPI:1063435899
Name:NEEDHAM, CHARLES SCOTT (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SCOTT
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 E RIVERSIDE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7063
Mailing Address - Country:US
Mailing Address - Phone:435-900-6001
Mailing Address - Fax:435-900-6001
Practice Address - Street 1:1841 E RIVERSIDE DR STE 102
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7063
Practice Address - Country:US
Practice Address - Phone:435-900-6001
Practice Address - Fax:435-900-6001
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188161-1205208G00000X
MT10916208G00000X
NV25878208G00000X
IDM-12600208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0151589OtherMDCD PIN
WY122226100OtherMDCD PIN
MT000092896OtherBCBS PIN
MT000085221Medicare PIN
MTH66122Medicare UPIN
WY122226100OtherMDCD PIN
MT1153260003Medicare PIN