Healthcare Provider Details

I. General information

NPI: 1417930256
Provider Name (Legal Business Name): CHARLES MACINTOSH CLIFFE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 7TH ST W
SAINT PAUL MN
55102-3828
US

IV. Provider business mailing address

5785 LAKE AVE
WHITE BEAR LAKE MN
55110-2364
US

V. Phone/Fax

Practice location:
  • Phone: 651-758-9500
  • Fax:
Mailing address:
  • Phone: 612-940-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36504
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: