Provider Demographics
NPI:1326042029
Name:MATHIS, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:MATHIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE STE 400
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-522-2284
Practice Address - Fax:574-522-3952
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041130A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200860370Medicaid
IN000000695205OtherANTHEM - RIVERPOINTE CARDIOLOGY
IN000000851311OtherBCBS NORTH CENTRAL CARDIOVACULAR
IN200860370Medicaid
IN000000851311OtherBCBS NORTH CENTRAL CARDIOVACULAR
IN100327860AMedicaid
IN236040034Medicare PIN
IN200860370Medicaid