Healthcare Provider Details

I. General information

NPI: 1013119528
Provider Name (Legal Business Name): CHARLEY B GATES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 COMMONS AVE
CORTLAND NY
13045-1643
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 607-758-3750
  • Fax:
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25541
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number258183
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD436074
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: