Provider Demographics
NPI:1437338068
Name:GAILLARD, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
Last Name:GAILLARD
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 524
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-0524
Mailing Address - Country:US
Mailing Address - Phone:803-245-2433
Mailing Address - Fax:803-245-7424
Practice Address - Street 1:526 NORTH ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1319
Practice Address - Country:US
Practice Address - Phone:803-245-2433
Practice Address - Fax:803-245-7424
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC423828OtherMEDICARE UNSPECIFIED
SCRHC151Medicaid
SCRHC020Medicaid
428926OtherMEDICARE UNSPECIFIED
SC423828OtherMEDICARE UNSPECIFIED