Provider Demographics
NPI:1629121553
Name:CHILTON MEDICAL GROUP P C
Entity Type:Organization
Organization Name:CHILTON MEDICAL GROUP P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:GANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-755-5700
Mailing Address - Street 1:108 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CLANTON
Mailing Address - State:AL
Mailing Address - Zip Code:35045-2332
Mailing Address - Country:US
Mailing Address - Phone:205-755-5700
Mailing Address - Fax:205-755-4966
Practice Address - Street 1:108 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-2332
Practice Address - Country:US
Practice Address - Phone:205-755-5700
Practice Address - Fax:888-418-7660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI206Medicare PIN