Healthcare Provider Details

I. General information

NPI: 1669445532
Provider Name (Legal Business Name): CHARLES RUSSELL ADCOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E 12TH ST
SOUTH PITTSBURG TN
37380-1633
US

IV. Provider business mailing address

520 E 12TH ST
SOUTH PITTSBURG TN
37380-1633
US

V. Phone/Fax

Practice location:
  • Phone: 423-837-7144
  • Fax: 423-837-8428
Mailing address:
  • Phone: 423-837-7144
  • Fax: 423-837-8428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD011688
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: