Provider Demographics
NPI:1528063609
Name:MEDBERY, CHARLES HENLEY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:HENLEY
Last Name:MEDBERY
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 1:5800 FOXRIDGE DR
Mailing Address - Street 2:STE 240
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2338
Mailing Address - Country:US
Mailing Address - Phone:913-261-3153
Mailing Address - Fax:913-262-3295
Practice Address - Street 1:401 WOODLAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-8797
Practice Address - Country:US
Practice Address - Phone:620-223-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-283532085R0202X
MO1072122085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00173775OtherRR MEDICARE
KS100171060CMedicaid
MO207821547Medicaid
KS100171060CMedicaid
KS104199Medicare PIN