Provider Demographics
NPI:1497751036
Name:BRENTNALL, CHARLES B JR (MD, PA)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:BRENTNALL
Suffix:JR
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL00007246207KA0200X, 207N00000X, 207NP0225X, 207Y00000X, 208600000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-02286OtherBLUE CROSS AND BLUE SHIED
AL510-19927OtherBLUECROSS/BLUE SHIELD
ALC71170Medicare UPIN