Healthcare Provider Details

I. General information

NPI: 1346351673
Provider Name (Legal Business Name): CHARLES RUDOLPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MOUSE CREEK RD NW
CLEVELAND TN
37312-3840
US

IV. Provider business mailing address

1025 PEERLESS XING NW
CLEVELAND TN
37312-3764
US

V. Phone/Fax

Practice location:
  • Phone: 423-458-1426
  • Fax: 423-790-1276
Mailing address:
  • Phone: 423-476-5990
  • Fax: 423-476-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD32155
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: