Provider Demographics
NPI:1104262096
Name:ALLDERDICE, CHARLES JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:ALLDERDICE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1924 ALCOA HIGHWAY
Mailing Address - Street 2:DEPARTMENT OF MEDICINE U-114 GSM, UTMCK
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920
Mailing Address - Country:US
Mailing Address - Phone:865-305-9340
Mailing Address - Fax:
Practice Address - Street 1:9320 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4301
Practice Address - Country:US
Practice Address - Phone:865-373-7100
Practice Address - Fax:865-374-2029
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN61180207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ058411Medicaid