Basic Information
| Provider Information | |||||||||
| NPI: | 1013119528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GATES | ||||||||
| FirstName: | CHARLEY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUTHRIE SQ | ||||||||
| Address2: | |||||||||
| City: | SAYRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708885858 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1104 COMMONS AVE | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130451643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077583750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2007 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 25541 | NE | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 258183 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | MD436074 | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 10025863500 | 05 | NE | MEDICAID | MD436074 | 01 | PA | MD LICENSE | OTHER | 34682 | 01 | NE | BLUECROSS BLUESHIELD | OTHER | P00840049 | 01 | RAILROAD MEDICARE | OTHER |