Healthcare Provider Details

I. General information

NPI: 1265662068
Provider Name (Legal Business Name): BRYAN JAMES CANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16555 MANCHESTER RD SUITE 100
WILDWOOD MO
63040-1220
US

IV. Provider business mailing address

16555 MANCHESTER RD SUITE 100
WILDWOOD MO
63040-1220
US

V. Phone/Fax

Practice location:
  • Phone: 636-458-0646
  • Fax:
Mailing address:
  • Phone: 636-458-0646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6038
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2016016732
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: