Provider Demographics
NPI:1740248863
Name:KINSELLA, CHARLES EN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EN
Last Name:KINSELLA
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 1:6047 BROKENHURST RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4987
Mailing Address - Country:US
Mailing Address - Phone:317-726-1213
Mailing Address - Fax:
Practice Address - Street 1:6047 BROKENHURST RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4987
Practice Address - Country:US
Practice Address - Phone:317-726-1213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041688A207RC0200X, 207R00000X, 207RS0012X
MOR3M79207RP1001X
IN01041688207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00183318OtherPROVIDER RAILROAD PIN
IN000000349806OtherPROVIDER ANTHEM PIN
IN201764827OtherPROVIDER CORP PIN
IN100218260AMedicaid
IN201764827OtherPROVIDER CORP PIN
IN221970BMedicare PIN