Healthcare Provider Details

I. General information

NPI: 1407831019
Provider Name (Legal Business Name): KEVIN H CONCANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2167 W ORANGE GROVE RD
TUCSON AZ
85741-3118
US

IV. Provider business mailing address

2167 W ORANGE GROVE RD
TUCSON AZ
85741-3118
US

V. Phone/Fax

Practice location:
  • Phone: 520-544-7650
  • Fax: 520-544-7627
Mailing address:
  • Phone: 520-544-7650
  • Fax: 520-544-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13231
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: