Provider Demographics
NPI:1841238649
Name:HINCKLEY, CHARLES DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:HINCKLEY
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 1:1634 W POLK ST
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4352
Mailing Address - Country:US
Mailing Address - Phone:312-423-4200
Mailing Address - Fax:312-829-3742
Practice Address - Street 1:1634 W POLK ST
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4352
Practice Address - Country:US
Practice Address - Phone:312-423-4200
Practice Address - Fax:312-829-3742
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA227236207R00000X, 208000000X
IL036121998208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAI51794Medicare UPIN