Provider Demographics
NPI:1114108164
Name:CHARLESTOWN PRIMARY CARE LLC
Entity Type:Organization
Organization Name:CHARLESTOWN PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-256-1106
Mailing Address - Street 1:3901 COUNTY ROAD 160
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9181
Mailing Address - Country:US
Mailing Address - Phone:812-406-6897
Mailing Address - Fax:812-256-3577
Practice Address - Street 1:3901 COUNTY ROAD 160
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9181
Practice Address - Country:US
Practice Address - Phone:812-406-6897
Practice Address - Fax:812-256-3577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061465A207Q00000X
IN71003560A363L00000X
IN71002399A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000549269OtherANTHEM GROUP NUMBER
IN20089454AMedicaid
IN20089454AMedicaid
IN255980Medicare PIN