=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003094731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES MCCAFFERTY, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2008
-----------------------------------------------------
Last Update Date | 02/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 977 SUMMIT AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-227-6369
-----------------------------------------------------
Fax | 651-227-9545
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 977 SUMMIT AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-3032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-227-6369
-----------------------------------------------------
Fax | 651-227-9545
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHARLES MCCAFFERTY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 651-227-6369
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 17268
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------