Provider Demographics
NPI:1902987407
Name:BROOK, GAYLE L (DO)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:L
Last Name:BROOK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SIGMA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7722
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:113 WILLBROOK BLVD UNIT F
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-8245
Practice Address - Country:US
Practice Address - Phone:843-353-6015
Practice Address - Fax:843-594-5149
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC411207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00754401OtherRAILROAD MC ID-RSFPN
SCT00111Medicaid
SC080188463OtherRAILROAD MEDICARE
SCG099759223Medicare PIN
SC7451Medicare PIN
SCP00754401OtherRAILROAD MC ID-RSFPN