MEDICARE: DR. CHARLES W NEAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1053380683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES W NEAL M.D.

Provider Business Mailing Address
First Line	:	17952 RESCUE CHURCH RD
Second Line	:
City	:	EWING
State	:	IL
Zip	:	62836-1001
Country	:	US
Telephone Number	:	618-629-2121
Fax Number	:

Provider Business Practice Location Address
First Line	:	4117 S WATER TOWER PL
Second Line	:	SUITE D
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6293
Country	:	US
Telephone Number	:	618-242-4848
Fax Number	:	618-242-4198

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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