Healthcare Provider Details

I. General information

NPI: 1104262096
Provider Name (Legal Business Name): CHARLES JOSEPH ALLDERDICE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 PARK WEST BLVD
KNOXVILLE TN
37923-4301
US

IV. Provider business mailing address

1924 ALCOA HIGHWAY DEPARTMENT OF MEDICINE U-114 GSM, UTMCK
KNOXVILLE TN
37920
US

V. Phone/Fax

Practice location:
  • Phone: 865-373-7100
  • Fax: 865-374-2029
Mailing address:
  • Phone: 865-305-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number61180
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number61180
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: