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General NPI Number Information
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NPI Number | 1366694887
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Entity Type | Individual
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Provider Name | CHARLES JOSEPH FAZIO M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/15/2008
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Last Update Date | 10/15/2008
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Provider Practice Location Address
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Address Line | 401 CARLSON PKWY MEDICA CP433
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City | MINNETONKA
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State | MN
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Zip | 55305-5359
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Country | US
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Telephone | 952-992-3056
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Fax |
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Provider Business Mailing Address
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Address Line | 401 CARLSON PKWY MEDICA CP433
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City | MINNETONKA
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State | MN
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Zip | 55305-5359
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Country | US
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Telephone | 952-992-3056
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 25504
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License Number State | MN
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