MEDICARE: DR. CHARLES HENRY LUDMER 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	2084P0800X	Psychiatry Physician		IL

General Provider Information

NPI Number	:	1366495608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES HENRY LUDMER M.D.

Provider Business Mailing Address
First Line	:	368 FOSS CT
Second Line	:
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-2753
Country	:	US
Telephone Number	:	847-295-0909
Fax Number	:	847-295-3636

Provider Business Practice Location Address
First Line	:	725 N MCKINLEY RD
Second Line	:	SUITE 100
City	:	LAKE FOREST
State	:	IL
Zip	:	60045-5508
Country	:	US
Telephone Number	:	847-295-0909
Fax Number	:	847-295-3636

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

Provider Enumeration Date	:	05/18/2006
Last Update Date	:	07/08/2007

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