Provider Demographics
NPI:1215080312
Name:CRECELIUS, CHARLES A (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:CRECELIUS
Suffix:
Gender:
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:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-273-4374
Mailing Address - Fax:314-983-0155
Practice Address - Street 1:10 BARNES WEST DR
Practice Address - Street 2:DIV IM GERIATRICS, STE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6287
Practice Address - Country:US
Practice Address - Phone:314-273-4374
Practice Address - Fax:314-983-0155
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7F42207R00000X, 207RG0300X, 207RG0300X
IL036154619207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202434734Medicaid
MOA10662Medicare UPIN
MO111112398Medicare ID - Type Unspecified