Provider Demographics
NPI:1326093774
Name:CANNAN, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:CANNAN
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 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5452
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:360-397-3128
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22152207RC0000X, 207RI0011X
WAMD00040793207RC0000X
AZ66585207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006442Medicaid
ORR162266Medicare PIN
ORR167272Medicare PIN
OR006442Medicaid
ORR171318Medicare PIN
ORR170060Medicare PIN