Basic Information
| Provider Information | |||||||||
| NPI: | 1346344975 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3407 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477333407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124506815 | ||||||||
| FaxNumber: | 8124506822 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MARY ST | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477470001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124503405 | ||||||||
| FaxNumber: | 8124503099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 01050225A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 35.073088 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200244470 | 05 | IN | MEDICAID | 000000380169 | 01 | IN | BCBS - GATEWAY | OTHER | 000000378775 | 01 | IN | BCBS - MARY STREET | OTHER | 64112824 | 05 | KY | MEDICAID |