Provider Demographics
NPI:1366646192
Name:GILLILAND, CHARLES ANDREW (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANDREW
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:613 23RD ST
Practice Address - Street 2:STE G30
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2878
Practice Address - Country:US
Practice Address - Phone:606-327-0036
Practice Address - Fax:606-329-1159
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44777207Q00000X, 207QS0010X
WV24275207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0053178Medicaid
KY7100176900Medicaid
OHH018430Medicare PIN
KY7100176900Medicaid