1477855450 NPI number — CHARLES C CANVER MD, MBA

Table of content: CHARLES C CANVER MD, MBA (NPI 1477855450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477855450 NPI number — CHARLES C CANVER MD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANVER
Provider First Name:
CHARLES
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477855450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1702 UNIVERSITY DR S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58103-4940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 32ND AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58103-6132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-364-8000
Provider Business Practice Location Address Fax Number:
573-302-2268
Provider Enumeration Date:
11/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  01060317A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 8603 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: 19268 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)