Individual
CHARLES K. BOLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
10 SAINT CLARE CT STE 100, WASHINGTON, IL 61571-9239
(309) 886-4000
(309) 886-4118
Mailing address
10 SAINT CLARE CT STE 100, WASHINGTON, IL 61571-9239
(309) 886-4000
(309) 886-4118
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036-115574
IL
208000000X
Pediatrics Physician
036-115574
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036115574
—
IL
01
—
833230
833230 - PONTIAC GROUP #
—
01
—
CA4079
RR GROUP
—
01
—
P00401636
RR MEDICARE
—
Enumeration date
04/24/2007
Last updated
06/06/2008
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