Provider Demographics
NPI:1013119528
Name:GATES, CHARLEY B (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLEY
Middle Name:B
Last Name:GATES
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1104 COMMONS AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1643
Practice Address - Country:US
Practice Address - Phone:607-758-3750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE25541207X00000X
NY258183207X00000X
PAMD436074207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025863500Medicaid
PAMD436074OtherMD LICENSE
NE34682OtherBLUECROSS BLUESHIELD
P00840049OtherRAILROAD MEDICARE
PAMD436074OtherMD LICENSE