Basic Information
| Provider Information | |||||||||
| NPI: | 1356325674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEOLEIAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5450 FRANTZ RD STE 360 | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430164141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6145446370 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837950 | ||||||||
| FaxNumber: | 7403758164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301054366 | MI | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 35.140177 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 10534 | 01 | MI | MCARE | OTHER | 133384 | 01 | MI | PREFERRED AND CARE CHOICE | OTHER | 4973505 | 05 | MI | MEDICAID | CK054366 | 01 | MI | BCBSM IDENTIFIER | OTHER | 4387203 | 05 | MI | MEDICAID | 340634410-1 | 01 | MI | BCBSM INDIVIDUAL ID | OTHER | 340019725 | 01 | MI | RAILROAD MEDICARE | OTHER | G14839 | 01 | MI | HAP | OTHER | 5281117 | 01 | MI | AETNA | OTHER |