Provider Demographics
NPI:1639367865
Name:CHAN, KERWIN T (MD)
Entity type:Individual
Prefix:
First Name:KERWIN
Middle Name:T
Last Name:CHAN
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 1:45 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1062
Mailing Address - Country:US
Mailing Address - Phone:651-232-3000
Mailing Address - Fax:
Practice Address - Street 1:45 10TH ST W STE A
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-013026207R00000X
IL036.125324207R00000X
IL036125324208M00000X
MN64525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125324OtherSTATE LICENSE
MN64525OtherSTATE LICENSE