Provider Demographics
NPI:1811996028
Name:WILLEY, CHARLES J (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:WILLEY
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 1:9915 KENNERLY RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2703
Mailing Address - Country:US
Mailing Address - Phone:314-843-4794
Mailing Address - Fax:314-843-9256
Practice Address - Street 1:9915 KENNERLY RD
Practice Address - Street 2:SUITE J
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2703
Practice Address - Country:US
Practice Address - Phone:314-843-4794
Practice Address - Fax:314-843-9256
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2010-07-15
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-06-20
Provider Licenses
StateLicense IDTaxonomies
MO13351174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0407220OtherUHC ST LOUIS MO
MO08221955OtherBCBS
MO138779OtherHEALTHLINK
MOA13558OtherMERCY
MO4001190OtherAETNA
MO000000010004OtherESSENCE ST LOUIS MO
MO0403389OtherUHC COLUMBIA IL
MO127507OtherGHP
IL0400221OtherUHC MEDICARE COMPLETE IL
IL000000012458OtherESSENCE COLUMBIA
MO0403389OtherUHC
MO25662OtherBCBS
MO0400101OtherUHC MEDICARE COMPLETE MO
IL25662OtherBCBS IL/MO TRI-ST
MO138779OtherHEALTHLINK
MO110114093Medicare PIN
IL25662OtherBCBS IL/MO TRI-ST
MO4001190OtherAETNA
MOA13558Medicare UPIN