Provider Demographics
NPI:1457369480
Name:CHARLES, PIERRE S (MD)
Entity Type:Individual
Prefix:
First Name:PIERRE
Middle Name:S
Last Name:CHARLES
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 1:1025 MAINE ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4038
Mailing Address - Country:US
Mailing Address - Phone:217-222-6550
Mailing Address - Fax:
Practice Address - Street 1:1025 MAINE ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4038
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37422020208600000X
IL036-119853208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457369480Medicaid
11205OtherDEAN HEALTH PLAN HMO
F400338762Medicare PIN
WI1457369480Medicaid
WI543300082Medicare PIN