Provider Demographics
NPI:1912913716
Name:REIDHEAD, CHARLES TYLER (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:TYLER
Last Name:REIDHEAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:TY
Other - Last Name:REIDHEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-1122
Practice Address - Street 1:200 W. HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-1122
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25107207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1780614008Medicaid
AZ1295993376Medicaid
AZ1629236716Medicaid
AZ1871523191Medicaid
AZ409856Medicaid
AZ1629236716Medicaid
AZH58458Medicare UPIN