Provider Demographics
NPI:1841466026
Name:SHIDEMAN, CHARLES RAYMOND (MD, PHD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RAYMOND
Last Name:SHIDEMAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
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Mailing Address - Street 1:7401 METRO BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3086
Mailing Address - Country:US
Mailing Address - Phone:952-920-4915
Mailing Address - Fax:952-915-6098
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-2039
Practice Address - Fax:651-254-9333
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN549922085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1841466026OtherNPI