Healthcare Provider Details

I. General information

NPI: 1508008574
Provider Name (Legal Business Name): MATTHEW G KANAAN DO , MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 11/13/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 BLUE RIDGE RD
RALEIGH NC
27612
US

IV. Provider business mailing address

3100 BLUE RIDGE RD
RALEIGH NC
27612-8036
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2010-01482
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: