Healthcare Provider Details

I. General information

NPI: 1659566388
Provider Name (Legal Business Name): JASON ANDREW CANNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453
US

IV. Provider business mailing address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-4094
  • Fax: 708-684-5141
Mailing address:
  • Phone: 708-684-4094
  • Fax: 708-684-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number34008593
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number036-120414
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: