MEDICARE: CHARLES BERNARD MCCANNA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	NM 76-67	NM
2	208D00000X	General Practice Physician	76-67	NM

General Provider Information

NPI Number	:	1730228214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES BERNARD MCCANNA M.D.

Provider Business Mailing Address
First Line	:	2063 PLACITA DE VIDA
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-5488
Country	:	US
Telephone Number	:	505-946-8790
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 ZAFARANO DR
Second Line	:	STE C
City	:	SANTA FE
State	:	NM
Zip	:	87507-2669
Country	:	US
Telephone Number	:	505-466-5885
Fax Number	:	505-466-5886

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	01/19/2017

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