Healthcare Provider Details

I. General information

NPI: 1003221532
Provider Name (Legal Business Name): CANNON SQUARE FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105A N MAIN AVE
NEWTON NC
28658-3213
US

IV. Provider business mailing address

105A N MAIN AVE
NEWTON NC
28658-3213
US

V. Phone/Fax

Practice location:
  • Phone: 828-291-3320
  • Fax: 828-241-2312
Mailing address:
  • Phone: 828-291-3320
  • Fax: 828-241-2312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number34551
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34551
License Number StateNC

VIII. Authorized Official

Name: DR. ROBERT GLENN AUTON JR.
Title or Position: MD/OWNER
Credential: MD
Phone: 828-292-3320