Provider Demographics
NPI:1902096647
Name:FANDEL, CHARLES E (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:FANDEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-2526
Mailing Address - Fax:715-848-2225
Practice Address - Street 1:1580 E KNOX ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-5300
Practice Address - Country:US
Practice Address - Phone:309-343-4418
Practice Address - Fax:309-343-4426
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038010920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07232019OtherBLUE CROSS/BLUE SHIELD
IL038010920Medicaid
IL07232019OtherBLUE CROSS/BLUE SHIELD
ILK44354Medicare PIN