MEDICARE: DR. CHARLES B BRENTNALL JR. M.D., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207KA0200X	Allergy Physician	00007246	AL
2	207N00000X	Dermatology Physician	00007246	AL
3	207NP0225X	Pediatric Dermatology Physician	00007246	AL
4	207Y00000X	Otolaryngology Physician	00007246	AL
5	208600000X	Surgery Physician	00007246	AL
6	2086S0122X	Plastic and Reconstructive Surgery Physician	00007246	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	510-02286	OTHER	AL	BLUE CROSS AND BLUE SHIED
2	510-19927	OTHER	AL	BLUECROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1497751036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES B BRENTNALL JR. M.D., P.A.

Provider Business Mailing Address
First Line	:	PO BOX 2190
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-5190
Country	:	US
Telephone Number	:	256-249-0358
Fax Number	:	256-249-8508

Provider Business Practice Location Address
First Line	:	7 BROWN AVE
Second Line	:
City	:	SYLACAUGA
State	:	AL
Zip	:	35150-2421
Country	:	US
Telephone Number	:	256-249-0358
Fax Number	:	256-249-8508

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	04/04/2008

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Directions to “ DR. CHARLES B BRENTNALL JR. M.D., P.A.” Practice Location

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