Basic Information
| Provider Information | |||||||||
| NPI: | 1598253577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2705 N LEBANON ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460528622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654858852 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2605 N LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460521476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654858000 | ||||||||
| FaxNumber: | 7654858239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2018 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 71007932A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 363LF0000X | 71007932A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 71007932A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3000013406 | 05 | IN | MEDICAID | 00001344950 | 01 | IN | ANTHEM | OTHER |