Provider Demographics
NPI:1851361976
Name:GILL, BRENT RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:RICHARD
Last Name:GILL
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 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-638-4023
Mailing Address - Fax:252-633-2833
Practice Address - Street 1:2604 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-4238
Practice Address - Country:US
Practice Address - Phone:252-638-4023
Practice Address - Fax:252-633-2833
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891173WMedicaid
NC891173WMedicaid