MEDICARE: DR. CHARLES RUDOLPH M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD32155	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
7	P00199940	OTHER	TN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	3148810	OTHER	TN	BCBS OF TENNESSEE
6	4150063	OTHER	TN	BLUE CROSS

General Provider Information

NPI Number	:	1346351673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES RUDOLPH M.D.

Provider Business Mailing Address
First Line	:	1025 PEERLESS XING NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-3764
Country	:	US
Telephone Number	:	423-476-5990
Fax Number	:	423-476-5887

Provider Business Practice Location Address
First Line	:	170 MOUSE CREEK RD NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-3840
Country	:	US
Telephone Number	:	423-458-1426
Fax Number	:	423-790-1276

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	04/22/2024

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Directions to “ DR. CHARLES RUDOLPH M.D.” Practice Location

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