Provider Demographics
NPI:1538254727
Name:CHARLES R. POTTER, M.D., L.L.C.
Entity type:Organization
Organization Name:CHARLES R. POTTER, M.D., L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-422-1199
Mailing Address - Street 1:1770 E LAKE SHORE DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3832
Mailing Address - Country:US
Mailing Address - Phone:217-422-1199
Mailing Address - Fax:217-422-1277
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:SUITE 306
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-422-1199
Practice Address - Fax:217-422-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065056207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty