Charles Waller, MD

Primary specialty

General Practice PhysicianTaxonomy code 208D00000X

License

29738 Issued in KY

Practice address

218 Bass LN
Benton, KY 42025-5824

Phone

(270) 556-3239

Fax

(270) 354-5865

NPI assigned

Jun 16, 2005

Last updated

Feb 1, 2017By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in KY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Southeastern Emergency Physicians LLC

  • Emergency Medicine Physician
  • Maysville, KY
  • NPI 1356379382
  Medicare reassignment NPD
• Trigg County Hospital, Inc

  • Critical Access Hospital
  • Cadiz, KY
  • NPI 1538218680

  Emergency Medicine

  Medicare reassignment NPD
• Hospital Medicine Services of Tennessee PC

  • Hospitalist Physician
  • Lawrenceburg, IN
  • NPI 1528433802

  KY

  Medicare reassignment NPD
• Trigg County Hospital, Inc

  dba Main Street Rural Health Clinic

  • Rural Health Clinic/Center
  • Cadiz, KY
  • NPI 1669103347
  NPD
• Ballard County Medical Center PSC

  • Family Medicine Physician
  • Barlow, KY
  • NPI 1932303294
  NPD (past)
• Jackson Purchase Medical Associates, PSC

  • Legal Medicine
  • Paducah, KY
  • NPI 1699850263
  NPD (past)
• Logan Emergency Group LLC

  • Nurse Practitioner
  • Russellville, KY
  • NPI 1770534752

  Emergency Medicine

  NPD (past)
• Marshall Emergency Services Associates, PLLC

  • Emergency Medicine Physician
  • Lexington, KY
  • NPI 1891737185
  NPD (past)
• Emergency Coverage Services, PC

  • Nurse Practitioner
  • Lawrenceburg, TN
  • NPI 1053351593
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1118880000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1485907200000",
    "number": "1306841341",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "218 BASS LN",
            "city": "BENTON",
            "state": "KY",
            "postal_code": "420255824",
            "telephone_number": "270-556-3239",
            "fax_number": "270-354-5865"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "218 BASS LN",
            "city": "BENTON",
            "state": "KY",
            "postal_code": "420255824",
            "telephone_number": "270-556-3239",
            "fax_number": "270-354-5865"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLER",
        "first_name": "CHARLES",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-06-16",
        "last_updated": "2017-02-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "KY",
            "license": "29738",
            "primary": true
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "KY",
            "license": "29738",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4047217",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "64297385",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Valaree Vinson
• Jayna Lynn Wade
• Garrison Scott Wagner, PHARMD
• Wal-Mart Stores East LP (Walmart Pharmacy 10-0143)
• Wal-Mart Stores East, LP (Vision Center 30-0143)
• Wendy Sowell Gibson OD
• West Kentucky Chiropractic and Performance Center (West Kentucky Chiropractic and Performance)
• Saundra H White, APRN
• Madison Brooke Wilkins, RBT
• James Blake Wiseman, PHARMD.

• General Practice Physician in Benton, KY
• Providers in Benton, KY by specialty
• General Practice Physician in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 1, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.