Provider Demographics
NPI:1316918345
Name:CHARLES ROYDEN STAUBS, LLC
Entity type:Organization
Organization Name:CHARLES ROYDEN STAUBS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUBS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:715-409-0121
Mailing Address - Street 1:850 NAUGART DR
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-9148
Mailing Address - Country:US
Mailing Address - Phone:715-409-0121
Mailing Address - Fax:
Practice Address - Street 1:850 NAUGART DR
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-9148
Practice Address - Country:US
Practice Address - Phone:715-409-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-28
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH42911207Q00000X
WI50267-21261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD045951800Medicaid
MDT843OtherCAREFIRST BC BS
MD253RMedicare ID - Type Unspecified
MDT843OtherCAREFIRST BC BS