Basic Information
| Provider Information | |||||||||
| NPI: | 1770858656 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | AUSTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5022725116 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E GRAY ST | ||||||||
| Address2: | SUITE 1105 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025831697 | ||||||||
| FaxNumber: | 5025832120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2012 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3007332 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000764051 | 01 | KY | ANTHEM - NNIKY | OTHER | 134996 | 01 | KY | SIHO - NNIKY | OTHER | 201067550 | 05 | IN | MEDICAID | 50038650 | 01 | KY | PASSPORT - NNIKY | OTHER | 7100201270 | 05 | KY | MEDICAID |