Provider Demographics
NPI:1821056649
Name:ALDERDICE, CHARLES RAY (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAY
Last Name:ALDERDICE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1906 LANGLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1739
Mailing Address - Country:US
Mailing Address - Phone:269-982-1722
Mailing Address - Fax:269-982-1842
Practice Address - Street 1:1906 LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1739
Practice Address - Country:US
Practice Address - Phone:269-982-1722
Practice Address - Fax:269-982-1842
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI015110022OtherBS
MI1607063Medicaid
MI010012749OtherMRRR
MI134870500OtherUSDEP
MI382531804OtherTRICA
MI382531804OtherTRICA
MI5110022Medicare ID - Type UnspecifiedMEDICARE