Provider Demographics
NPI:1679539902
Name:TOMBERLIN, CHARLES GARY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:GARY
Last Name:TOMBERLIN
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:PO BOX 27
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1200
Mailing Address - Country:US
Mailing Address - Phone:334-222-5673
Mailing Address - Fax:334-222-8754
Practice Address - Street 1:848 S 3 NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5320
Practice Address - Country:US
Practice Address - Phone:334-222-5673
Practice Address - Fax:334-222-8754
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL32332085N0904X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000006385Medicaid
AL0000006385Medicare NSC
ALC76314Medicare UPIN
ALCM1269Medicare PIN