Healthcare Provider Details

I. General information

NPI: 1508973918
Provider Name (Legal Business Name): CHARLES S. HALBECK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 E. 5TH ST.
ALTON IL
62002-6471
US

IV. Provider business mailing address

915 E. 5TH ST.
ALTON IL
62002-6471
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-5300
  • Fax: 618-463-5195
Mailing address:
  • Phone: 618-463-5300
  • Fax: 618-463-5195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036061328
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberR2F64
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.061328
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: