Basic Information
| Provider Information | |||||||||
| NPI: | 1629121553 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILTON MEDICAL GROUP P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CLANTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350452332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057555700 | ||||||||
| FaxNumber: | 2057554966 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CLANTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350452332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057555700 | ||||||||
| FaxNumber: | 2057554966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 01/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | MARCUS | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2057555700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
No ID Information.