Basic Information
| Provider Information | |||||||||
| NPI: | 1407896749 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CANONICO | ||||||||
| FirstName: | ANGELO | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 WOODMONT BLVD | ||||||||
| Address2: | SUITE LL50 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153862300 | ||||||||
| FaxNumber: | 6153862399 | ||||||||
| Practice Location | |||||||||
| Address1: | 4230 HARDING RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372052013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152972700 | ||||||||
| FaxNumber: | 6152694584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
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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 | 207RP1001X | 19712 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207R00000X | 019712 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 258288 | 01 | TN | USA MCO | OTHER | 3164295 | 01 | TN | BLUE CROSS OF TN | OTHER | 64916679 | 05 | KY | MEDICAID | 12079668 | 01 | TN | MULTIPLAN/PHCS | OTHER | 1510392 | 05 | TN | MEDICAID | 290013543 | 01 | TN | MEDICARE RR | OTHER | 5541480 | 01 | TN | CIGNA | OTHER | 982568 | 01 | TN | UNITED HEALTHCARE | OTHER | 1510158 | 05 | TN | MEDICAID |