MEDICARE: DR. CHARLES RAY ALDERDICE D.O.

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	207Q00000X	Family Medicine Physician	5101008526	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	015110022	OTHER	MI	BS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	010012749	OTHER	MI	MRRR
4	134870500	OTHER	MI	USDEP
5	382531804	OTHER	MI	TRICA

General Provider Information

NPI Number	:	1821056649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES RAY ALDERDICE D.O.

Provider Business Mailing Address
First Line	:	1906 LANGLEY AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-1739
Country	:	US
Telephone Number	:	269-982-1722
Fax Number	:	269-982-1842

Provider Business Practice Location Address
First Line	:	1906 LANGLEY AVE
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-1739
Country	:	US
Telephone Number	:	269-982-1722
Fax Number	:	269-982-1842

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

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	07/01/2010

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