Provider Demographics
NPI:1437309234
Name:CHARLES, BERNARD R (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:R
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-0053
Mailing Address - Country:US
Mailing Address - Phone:815-630-5119
Mailing Address - Fax:
Practice Address - Street 1:301 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-630-5119
Practice Address - Fax:815-630-3126
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121755208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121755OtherSTATE LICENSED