Basic Information
Provider Information | |||||||||
NPI: | 1356318679 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GERTLER | ||||||||
FirstName: | CHARLES | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3726 | ||||||||
Address2: |   | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309143726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068639595 | ||||||||
FaxNumber: | 7068607124 | ||||||||
Practice Location | |||||||||
Address1: | 3675 J DEWEY GRAY CIRCLE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | AUGUSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 309091868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068639595 | ||||||||
FaxNumber: | 7068607124 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2006 | ||||||||
LastUpdateDate: | 01/07/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 000857 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 0213PA | 05 | GA |   | MEDICAID | 100002356A | 05 | GA |   | MEDICAID |