Basic Information
| Provider Information | |||||||||
| NPI: | 1215989322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELDREDGE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 FRENCH RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134131044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157353541 | ||||||||
| FaxNumber: | 3157243255 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 FRENCH RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | NEW HARTFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134131044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157353541 | ||||||||
| FaxNumber: | 3157243255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 165839 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207R00000X | 165839 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01070199 | 05 | NY | MEDICAID |