Healthcare Provider Details

I. General information

NPI: 1962563536
Provider Name (Legal Business Name): CHARLES BRIEN GODFREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 HIGHWAY 13 E SUITE 116
BURNSVILLE MN
55337-2884
US

IV. Provider business mailing address

501 HIGHWAY 13 E SUITE 116
BURNSVILLE MN
55337-2884
US

V. Phone/Fax

Practice location:
  • Phone: 651-365-3606
  • Fax: 651-681-9317
Mailing address:
  • Phone: 651-365-3606
  • Fax: 651-681-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26058
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number26058
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: