Individual
JEROME G. CHARLES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
211 N BROADWAY STE 105, GREEN BAY, WI 54303-2757
(920) 432-9040
(920) 432-9053
Mailing address
4000 N PROVIDENCE AVE, APPLETON, WI 54913-8018
(920) 257-2005
(920) 257-2004
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2921-024
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000486021
MEDICARE
WI
01
—
001686030
MEDICARE
WI
01
—
115015
SECURITY HEALTH PLAN
WI
05
—
40309000
—
WI
01
—
650018183
RAILROAD MEDICARE
WI
01
—
650025343
RAILROAD MEDICARE
—
Enumeration date
07/19/2006
Last updated
06/25/2013
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