Provider Demographics
NPI:1407948805
Name:PAN, CHARLIE C (MD)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:C
Last Name:PAN
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:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:B2 FLOOR UNIVERSITY HOSPITAL RM C490
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-0010
Practice Address - Country:US
Practice Address - Phone:734-936-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010746642085R0001X
WI54475-202085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4660707Medicaid
MI4660707Medicaid
MI0H16056059Medicare ID - Type Unspecified