Provider Demographics
NPI:1629053459
Name:BISHOP, CHARLES G JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:BISHOP
Suffix:JR
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 1:1326 RAINFIELD GARDENS COURT
Mailing Address - Street 2:
Mailing Address - City:O'FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269
Mailing Address - Country:US
Mailing Address - Phone:618-531-6818
Mailing Address - Fax:
Practice Address - Street 1:12 GINGER CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-656-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106182207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106182Medicaid
IL036106182Medicaid