Provider Demographics
NPI:1518653401
Name:HILL, CHARLES GILBERT IV (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GILBERT
Last Name:HILL
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2 RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-2466
Mailing Address - Country:US
Mailing Address - Phone:636-633-0102
Mailing Address - Fax:
Practice Address - Street 1:12680 OLIVE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6322
Practice Address - Country:US
Practice Address - Phone:314-251-6062
Practice Address - Fax:314-251-8889
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023024562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty