Basic Information
Provider Information | |||||||||
NPI: | 1699786699 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CANNON EMERGENCY PHYSICIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 815 S PALAFOX ST | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325025937 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004447009 | ||||||||
FaxNumber: | 8003053233 | ||||||||
Practice Location | |||||||||
Address1: | 1110 N SARAH DEWITT DR | ||||||||
Address2: | EMERGENCY DEPARTMENT | ||||||||
City: | GONZALES | ||||||||
State: | TX | ||||||||
PostalCode: | 786293311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8306727581 | ||||||||
FaxNumber: | 8306724319 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2006 | ||||||||
LastUpdateDate: | 03/06/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GATEWOOD | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | PRES TEXAS EMER ROOM SERVICES PA | ||||||||
AuthorizedOfficialTelephone: | 8004272145 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0030LE | 01 | TX | BS GRP # - GONZALES, TX | OTHER |