Basic Information
| Provider Information | |||||||||
| NPI: | 1154393049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENLEY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502805 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462246977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179579050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3508 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01588239 | 01 | IN | RAILROAD PTAN | OTHER | 100031740D | 05 | OK | MEDICAID |