Healthcare Provider Details

I. General information

NPI: 1801090626
Provider Name (Legal Business Name): CHARLES BENJAMIN PALMER IV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 FOREST GREEN BLVD STE 112
LOUISVILLE KY
40223-5167
US

IV. Provider business mailing address

PO BOX 776347
CHICAGO IL
60677-6347
US

V. Phone/Fax

Practice location:
  • Phone: 877-866-7123
  • Fax:
Mailing address:
  • Phone: 502-272-5052
  • Fax: 502-629-6217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2011-00750
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number04495
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS018028
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: