Basic Information
| Provider Information | |||||||||
| NPI: | 1346298049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONCANNON | ||||||||
| FirstName: | MILTON | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012491350 | ||||||||
| FaxNumber: | 6012491339 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012491350 | ||||||||
| FaxNumber: | 6012491339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2013 | ||||||||
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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 | 207RC0000X | 13399 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 174400000X | 13399 | MS | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00115292 | 05 | MS | MEDICAID |