Provider Demographics
NPI:1871586701
Name:REBESCO, CHARLES J (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:REBESCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7875 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:IN
Mailing Address - Zip Code:46342-6665
Mailing Address - Country:US
Mailing Address - Phone:219-942-9658
Mailing Address - Fax:219-947-1996
Practice Address - Street 1:7875 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6665
Practice Address - Country:US
Practice Address - Phone:219-942-9658
Practice Address - Fax:219-947-1996
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031652174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100379590AMedicaid
IN704270BMedicare ID - Type Unspecified
IND95578Medicare UPIN
IN704270BMedicare PIN