Provider Demographics
NPI:1639351562
Name:DR.CHARLES W. KEBLUSEK
Entity Type:Organization
Organization Name:DR.CHARLES W. KEBLUSEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-379-0094
Mailing Address - Street 1:1409 HUGUENOT RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2603
Mailing Address - Country:US
Mailing Address - Phone:804-379-0094
Mailing Address - Fax:804-379-9701
Practice Address - Street 1:1409 HUGUENOT RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2603
Practice Address - Country:US
Practice Address - Phone:804-379-0094
Practice Address - Fax:804-379-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
065061OtherANTHEM PROVIDER NUMBER
B09610Medicare UPIN
C03461Medicare PIN