Healthcare Provider Details

I. General information

NPI: 1114108164
Provider Name (Legal Business Name): CHARLESTOWN PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 COUNTY ROAD 160
CHARLESTOWN IN
47111-9181
US

IV. Provider business mailing address

3901 COUNTY ROAD 160
CHARLESTOWN IN
47111-9181
US

V. Phone/Fax

Practice location:
  • Phone: 812-406-6897
  • Fax: 812-256-3577
Mailing address:
  • Phone: 812-406-6897
  • Fax: 812-256-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71003560A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002399A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01061465A
License Number StateIN

VIII. Authorized Official

Name: DR. WILLAM E HOKE
Title or Position: MEMBER
Credential: MD
Phone: 812-256-1106