Provider Demographics
NPI:1477628667
Name:STILLERMAN, CHARLES BLAIR (MD, FACS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BLAIR
Last Name:STILLERMAN
Suffix:
Gender:
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 N MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112-1103
Mailing Address - Country:US
Mailing Address - Phone:801-581-6908
Mailing Address - Fax:801-581-4385
Practice Address - Street 1:175 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-6967
Practice Address - Country:US
Practice Address - Phone:801-581-6908
Practice Address - Fax:801-581-4385
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6059746-1205207T00000X
NJ25MA 08659500207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0289043Medicaid
E33435Medicare UPIN
NJ0289043Medicaid