Provider Demographics
NPI:1710935325
Name:KERSHNER, CHARLES R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:KERSHNER
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 1:2110 E BOCOCK RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-8663
Mailing Address - Country:US
Mailing Address - Phone:765-662-3156
Mailing Address - Fax:
Practice Address - Street 1:285 W 12TH ST
Practice Address - Street 2:106
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1653
Practice Address - Country:US
Practice Address - Phone:765-472-8041
Practice Address - Fax:765-475-8956
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01019780207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100352280Medicaid
IN100123310Medicaid
IN000000082968OtherANTHEM BCBS
IN000000608142OtherANTHEM
IN292270Medicare PIN
IN000000608142OtherANTHEM
IN100123310Medicaid
IN261120Medicare PIN