Basic Information
| Provider Information | |||||||||
| NPI: | 1124077912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONOVAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7505 METRO BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554393010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Practice Location | |||||||||
| Address1: | 7505 METRO BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125732200 | ||||||||
| FaxNumber: | 6125732274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 48603 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2443230 | 01 | MN | AMERICA'S PPO | OTHER | 505P3DO | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | HP63008 | 01 | MN | HEALTHPARTNERS | OTHER | 99112184 | 01 | WI | WI HEALTH INSURANCE RISK SHARING PLAN | OTHER | 0721050 | 05 | IA | MEDICAID | 16-04146 | 01 | MN | MEDICA | OTHER | 252817 | 01 | MN | MIDLANDS CHOICE INC | OTHER | 1046956 | 01 | MN | PREFERRED ONE | OTHER | 9103415 | 01 | MN | PHCS/MULTIPLAN | OTHER | P00327700 | 01 | MN | RAILROAD MEDICARE MN | OTHER | 133042 | 01 | MN | UCARE | OTHER | P00327697 | 01 | WI | RAILROAD MEDICARE WI | OTHER | 34864100 | 05 | WI | MEDICAID | 621966700 | 05 | MN | MEDICAID |