Healthcare Provider Details

I. General information

NPI: 1851384093
Provider Name (Legal Business Name): BRIAN A CANAVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 10/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S FIRST AVENUE LOYOLA UNIVERSITY MEDICAL CENTER
CHICAGO IL
60153
US

IV. Provider business mailing address

225 N COLUMBUS DR APT 2403
CHICAGO IL
60601-7910
US

V. Phone/Fax

Practice location:
  • Phone: 617-838-3852
  • Fax:
Mailing address:
  • Phone: 617-838-3852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036.118840
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: