Provider Demographics
NPI:1114944113
Name:BREEN, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:BREEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E CALDONIA AVE, PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:ND
Mailing Address - Zip Code:58045
Mailing Address - Country:US
Mailing Address - Phone:701-436-5311
Mailing Address - Fax:701-436-4514
Practice Address - Street 1:315 E CALDONIA AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:ND
Practice Address - Zip Code:58045
Practice Address - Country:US
Practice Address - Phone:701-436-5311
Practice Address - Fax:701-436-4514
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND6161207Q00000X
MN36008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17292Medicaid
ND17292Medicaid
E85281Medicare UPIN
NDN4895Medicare PIN