Healthcare Provider Details

I. General information

NPI: 1215927223
Provider Name (Legal Business Name): CHARLES B GILLS NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 HOSPITAL DR
NORTHPORT AL
35476-3360
US

IV. Provider business mailing address

8530 DIAMOND OAK DR
TUSCALOOSA AL
35405-7418
US

V. Phone/Fax

Practice location:
  • Phone: 205-366-3334
  • Fax:
Mailing address:
  • Phone: 205-759-2186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1074860
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: