Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 46524 | MN |
N | 207PP0204X | Pediatric Emergency Physician | 46524 | MN |
N | 208000000X | Pediatrician | 46524 | MN |
N | 2080P0204X | Pediatric Emergency Doctor | 46524 | MN |
NPI | 1750492856 |
---|---|
Provider Name | Charles D Blackwell III |
First Address | Roseville, MN 55113 |
Second Address | Minneapolis, MN 55404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H33754 | (02) |