Provider Demographics
NPI:1396126165
Name:KIDD, CHARLES ALEXANDER (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALEXANDER
Last Name:KIDD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:RESIDENT ENROLLMENT
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-455-7844
Mailing Address - Fax:
Practice Address - Street 1:207 ELK AVE S
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3051
Practice Address - Country:US
Practice Address - Phone:931-433-2551
Practice Address - Fax:931-438-0069
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38504207R00000X, 208000000X
TN56894207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics