Provider Demographics
NPI:1972807147
Name:C R ALDERDICE D O
Entity Type:Organization
Organization Name:C R ALDERDICE D O
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDERDICE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-982-1722
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1607063Medicaid
5083312OtherAETNA PIN
5110022OtherMEDICARE PTAN
MI5110022OtherBLUE CROSS
5110022OtherMEDICARE PTAN