Provider Demographics
NPI:1659471613
Name:EDWARDS, CHARLES THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:THOMAS
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-689-6049
Mailing Address - Fax:309-689-6092
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 218
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-693-2244
Practice Address - Fax:309-693-7606
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23523Medicare ID - Type UnspecifiedMEMBER NUMBER