Provider Demographics
NPI:1912126640
Name:BOLEY, CHARLES K
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:K
Last Name:BOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SAINT CLARE CT STE 100
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9239
Mailing Address - Country:US
Mailing Address - Phone:309-886-4000
Mailing Address - Fax:309-886-4118
Practice Address - Street 1:10 SAINT CLARE CT STE 100
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-9239
Practice Address - Country:US
Practice Address - Phone:309-886-4000
Practice Address - Fax:309-886-4118
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115574207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00401636OtherRR MEDICARE
833230Other833230 - PONTIAC GROUP #
CA4079OtherRR GROUP
IL036115574Medicaid
IL036115574Medicaid
R01112 PONTIACMedicare PIN
ILK38877Medicare PIN