Basic Information
Provider Information | |||||||||
NPI: | 1174876999 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANNON MEDICAL CLINIC INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13000 N 103RD AVE STE 97 | ||||||||
Address2: |   | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853513060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239331337 | ||||||||
FaxNumber: | 6239336109 | ||||||||
Practice Location | |||||||||
Address1: | 13000 N 103RD AVE #97 | ||||||||
Address2: |   | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853513060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6239331337 | ||||||||
FaxNumber: | 6239336109 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2012 | ||||||||
LastUpdateDate: | 10/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CANNON | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | LEE | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6239331337 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | AZ4549 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.