Provider Demographics
NPI:1225057912
Name:CHARLES, JEROME G (PT)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:G
Last Name:CHARLES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 N PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8018
Mailing Address - Country:US
Mailing Address - Phone:920-257-2005
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:211 N BROADWAY STE 105
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2757
Practice Address - Country:US
Practice Address - Phone:920-432-9040
Practice Address - Fax:920-432-9053
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2921-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI115015OtherSECURITY HEALTH PLAN
WI650018183OtherRAILROAD MEDICARE
650025343OtherRAILROAD MEDICARE
WI000486021OtherMEDICARE
WI001686030OtherMEDICARE
WI40309000Medicaid
WI000486021OtherMEDICARE
650025343OtherRAILROAD MEDICARE
WIS85211Medicare UPIN