Provider Demographics
NPI:1356325674
Name:KEOLEIAN, CHARLES M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:KEOLEIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5450 FRANTZ RD STE 360
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-4141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:614-544-6370
Practice Address - Street 1:1040 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-383-7950
Practice Address - Fax:740-375-8164
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054366208800000X
OH35.140177208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10534OtherMCARE
MI133384OtherPREFERRED AND CARE CHOICE
MI4973505Medicaid
MICK054366OtherBCBSM IDENTIFIER
MI4387203Medicaid
MI340634410-1OtherBCBSM INDIVIDUAL ID
MI340019725OtherRAILROAD MEDICARE
MIG14839OtherHAP
MI5281117OtherAETNA
MI340634410-1OtherBCBSM INDIVIDUAL ID
MI5281117OtherAETNA