Provider Demographics
NPI:1659336220
Name:SWAN, CHARLES M (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:M
Last Name:SWAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 42ND ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546
Mailing Address - Country:US
Mailing Address - Phone:812-482-4900
Mailing Address - Fax:
Practice Address - Street 1:201 42ND ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-8222
Practice Address - Country:US
Practice Address - Phone:812-482-4900
Practice Address - Fax:812-492-4900
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002122A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000483883OtherBLUE CROSS
215030Medicare ID - Type Unspecified
U99235Medicare UPIN