Provider Demographics
NPI:1003370834
Name:BALES, MARYCHARLOTTE TURNER (PT)
Entity Type:Individual
Prefix:
First Name:MARYCHARLOTTE
Middle Name:TURNER
Last Name:BALES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARYCHARLOTTE
Other - Middle Name:
Other - Last Name:GERBIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:426 S ALABAMA ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46225-3301
Practice Address - Country:US
Practice Address - Phone:317-528-6804
Practice Address - Fax:317-528-3781
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070024084225100000X
IN05014056A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM147140325OtherMEDICARE