Healthcare Provider Details

I. General information

NPI: 1326769175
Provider Name (Legal Business Name): MICHAEL CANNON, MD PERSONALIZED MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16216 BAXTER RD STE 340
CHESTERFIELD MO
63017-4778
US

IV. Provider business mailing address

PO BOX 221240
KIRKWOOD MO
63122-8240
US

V. Phone/Fax

Practice location:
  • Phone: 314-325-8925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CANNON
Title or Position: OWNER/ MD
Credential:
Phone: 314-574-2851