Basic Information
| Provider Information | |||||||||
| NPI: | 1609840313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 N CEDAR BLUFF RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379233632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313886404 | ||||||||
| FaxNumber: | 9313887119 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 TUCKER STREET | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313886404 | ||||||||
| FaxNumber: | 9313887119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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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 | 207L00000X | MD16686 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3026238 | 05 | TN | MEDICAID |