Provider Demographics
NPI:1861429615
Name:PRINCE, CHARLES (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-367-4500
Mailing Address - Fax:502-368-8139
Practice Address - Street 1:1900 BLUEGRASS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1144
Practice Address - Country:US
Practice Address - Phone:502-367-4500
Practice Address - Fax:502-368-8139
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25560207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64004864Medicaid
KY64004864Medicaid
KYK000553Medicare Oscar/Certification
KY64004864Medicaid