Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 00007246 | AL |
N | 207N00000X | Dermatologist | 00007246 | AL |
N | 207NP0225X | Pediatric Dermatologist | 00007246 | AL |
N | 207Y00000X | Otolaryngologist (ENT Doctor) | 00007246 | AL |
N | 208200000X | Surgeon | 00007246 | AL |
N | 208600000X | Surgeon | 00007246 | AL |
N | 2086S0122X | Plastic and Reconstructive Surgery | 00007246 | AL |
NPI | 1497751036 |
---|---|
Provider Name | Dr. Charles B Brentnall JR. |
First Address | Sylacauga, AL 35150-5190 |
Second Address | Sylacauga, AL 35150-2421 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2005 |
Last Update Date | 04/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
510-02286 | BLUE CROSS AND BLUE SHIED (01) | AL |
510-19927 | BLUECROSS/BLUE SHIELD (01) | AL |
C71170 | (02) | AL |