Basic Information
| Provider Information | |||||||||
| NPI: | 1639367865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | KERWIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512323000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 10TH ST W STE A | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512323000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2007 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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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 | 207R00000X | 57-013026 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 036.125324 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 036125324 | IL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 64525 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036125324 | 01 | IL | STATE LICENSE | OTHER | 64525 | 01 | MN | STATE LICENSE | OTHER |