Provider Demographics
NPI:1023280716
Name:CHARLES BRENTNALL, M.D., P.A.
Entity type:Organization
Organization Name:CHARLES BRENTNALL, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRENTNALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-249-0358
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150-5190
Mailing Address - Country:US
Mailing Address - Phone:256-249-0358
Mailing Address - Fax:256-249-8508
Practice Address - Street 1:7 BROWN AVE
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2421
Practice Address - Country:US
Practice Address - Phone:256-249-0358
Practice Address - Fax:256-249-8508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-02286OtherBCBS OF ALABAMA
AL000019927Medicaid
ALC71170OtherUPIN
AL000002286Medicaid
AL510-19927OtherBCBS OF ALABAMA
AL000019927Medicaid
AL510-19927OtherBCBS OF ALABAMA