Healthcare Provider Details

I. General information

NPI: 1295537355
Provider Name (Legal Business Name): CHARLES WILLIAMS PHLEBOTOMIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E 96TH ST STE 500
INDIANAPOLIS IN
46240-3760
US

IV. Provider business mailing address

450 E 96TH ST STE 500
INDIANAPOLIS IN
46240-3760
US

V. Phone/Fax

Practice location:
  • Phone: 317-744-4504
  • Fax:
Mailing address:
  • Phone: 317-744-4504
  • Fax: 317-600-2837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number2646
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number2646
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: