Basic Information
| Provider Information | |||||||||
| NPI: | 1497744254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANNON MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ANMED CANNON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 123 W G ACKER DR | ||||||||
| Address2: | |||||||||
| City: | PICKENS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296712739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648984791 | ||||||||
| FaxNumber: | 8648991047 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 W G ACKER DR | ||||||||
| Address2: | |||||||||
| City: | PICKENS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296712739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648784791 | ||||||||
| FaxNumber: | 8648981047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUNNINGHAM | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8645121109 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | HTL-076 | SC | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 205007 | 05 | SC | MEDICAID | 400113 | 05 | SC | MEDICAID | 4200011 | 05 | NC | MEDICAID | 89066XH | 05 | NC | MEDICAID | CM6374 | 01 | SC | MEDICARE RAILROAD | OTHER | 42-U011 | 01 | SC | MEDICARE SWING BED UNIT | OTHER | 420011 | 01 | SC | MEDICARE I/P & O/P | OTHER | 420011 | 01 | SC | MEDICARE INPATIENT | OTHER | 300017386A | 05 | GA | MEDICAID | 382878 | 05 | SC | MEDICAID |