| Name: | Charles Brentnall, M.D., P.A. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Association |
| Status: | Dissolved |
| Date of registration: | 01 Jul 1982 (42 years ago) |
| Date of dissolution: | 28 Dec 2021 |
| Entity Number: | 000-820-116 |
| Register Number: | 000820116 |
| County: | Talladega |
| Place of Formation: | Talladega County |
| Principal Address: | 3520 TALLADEGA HWYSYLACAUGA, AL 35150 |
| Principal Address ZIP Code: | 35150 |
Activities
MEDICAL PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1023280716 | 2008-04-02 | 2008-05-01 | PO BOX 2190, SYLACAUGA, AL, 351505190, US | 7 BROWN AVE, SYLACAUGA, AL, 351502421, US | |||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 256-249-0358 |
| Fax | 2562498508 |
Authorized person
| Name | DR. CHARLES B BRENTNALL |
| Role | PRESIDENT |
| Phone | 2562490358 |
Taxonomy
| Taxonomy Code | 174400000X - Specialist |
| License Number | 00007246 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS OF ALABAMA |
| Number | 510-02286 |
| State | AL |
| Issuer | MEDICAID |
| Number | 000019927 |
| State | AL |
| Issuer | UPIN |
| Number | C71170 |
| State | AL |
| Issuer | MEDICAID |
| Number | 000002286 |
| State | AL |
| Issuer | BCBS OF ALABAMA |
| Number | 510-19927 |
| State | AL |
| Name | Role |
|---|---|
| BRENTNALL, CHARLES | Member |
Date of last update: 16 Aug 2024
Sources: Alabama Secretary of State
