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General NPI Number Information
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NPI Number | 1770582983
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Entity Type | Individual
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Provider Name | JEFFREY R. CANHAM M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/19/2005
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 302 W HAY ST SUITE 200
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City | DECATUR
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State | IL
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Zip | 62526-4167
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Country | US
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Telephone | 217-877-8925
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Fax | 217-877-0020
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Provider Business Mailing Address
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Address Line | 4431 COUNTRY MANOR CT
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City | DECATUR
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State | IL
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Zip | 62521-2520
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Country | US
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Telephone | 217-422-8300
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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 | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 036-060206
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License Number State | IL
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