Healthcare Provider Details

I. General information

NPI: 1174504252
Provider Name (Legal Business Name): CHARLES A ATHILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 BERGER AVE SUITE 200
SAN DIEGO CA
92123-4233
US

IV. Provider business mailing address

3131 BERGER AVE SUITE 200
SAN DIEGO CA
92123-4233
US

V. Phone/Fax

Practice location:
  • Phone: 858-244-6800
  • Fax: 858-244-6909
Mailing address:
  • Phone: 858-244-6800
  • Fax: 858-244-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberG78671
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG78671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: