Healthcare Provider Details

I. General information

NPI: 1558358507
Provider Name (Legal Business Name): CHARLES MARTIN KENDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SKYLINE BLVD
CLOQUET MN
55720-1199
US

IV. Provider business mailing address

512 SKYLINE BLVD
CLOQUET MN
55720-1199
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-4641
  • Fax: 218-879-9167
Mailing address:
  • Phone: 218-879-4641
  • Fax: 218-879-9167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34533
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: