Provider Demographics
NPI:1174576920
Name:CHARLES E ANDERESON MD PC
Entity type:Organization
Organization Name:CHARLES E ANDERESON MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-393-0600
Mailing Address - Street 1:2336 N JACKSON ST
Mailing Address - Street 2:PO BOX 1840
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-393-0600
Mailing Address - Fax:931-393-0656
Practice Address - Street 1:2336 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-393-0600
Practice Address - Fax:931-393-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14122208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3197128Medicaid
TN4009762OtherBCBS OF TN
TN7240951OtherCIGNA HEALTH CARE
TN3197128Medicare ID - Type Unspecified
B59539Medicare UPIN