Basic Information
| Provider Information | |||||||||
| NPI: | 1104262096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLDERDICE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1924 ALCOA HIGHWAY | ||||||||
| Address2: | DEPARTMENT OF MEDICINE U-114 GSM, UTMCK | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653059340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9320 PARK WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653737100 | ||||||||
| FaxNumber: | 8653742029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2013 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 61180 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 61180 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | Q058411 | 05 | TN | MEDICAID |