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General NPI Number Information
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NPI Number | 1851384093
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Entity Type | Individual
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Provider Name | BRIAN A CANAVAN MD
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Gender | Male
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Dates
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Enumeration Date | 08/23/2005
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Last Update Date | 10/07/2010
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Provider Practice Location Address
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Address Line | 2160 S FIRST AVENUE LOYOLA UNIVERSITY MEDICAL CENTER
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City | CHICAGO
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State | IL
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Zip | 60153
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Country | US
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Telephone | 617-838-3852
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Fax |
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Provider Business Mailing Address
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Address Line | 225 N COLUMBUS DR APT 2403
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City | CHICAGO
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State | IL
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Zip | 60601-7910
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Country | US
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Telephone | 617-838-3852
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | 036.118840
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License Number State | IL
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