Provider Demographics
NPI:1558584086
Name:GILLILAND, CHARLES ARTHUR IV (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ARTHUR
Last Name:GILLILAND
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 200096
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-9002
Mailing Address - Country:US
Mailing Address - Phone:770-607-7339
Mailing Address - Fax:678-905-7053
Practice Address - Street 1:1133 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5085
Practice Address - Country:US
Practice Address - Phone:770-607-7339
Practice Address - Fax:678-905-7053
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA722642085R0202X, 2085R0204X
TNRADIOLOGY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2011016762OtherLICENSE
TNAM0395168-6116OtherDEA NUMBER