Basic Information
| Provider Information | |||||||||
| NPI: | 1023092897 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 W MILLER DR | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530926189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628258984 | ||||||||
| FaxNumber: | 2624477330 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N 9TH ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 2177576844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 036-112376 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036112376 | 05 | IL | MEDICAID |