Healthcare Provider Details

I. General information

NPI: 1609107069
Provider Name (Legal Business Name): GLENN MARTIN CANNON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS HOSPITAL DR 4401 PENN AVENUE
PITTSBURGH PA
15224-1529
US

IV. Provider business mailing address

200 LOTHROP ST FORBES TOWER, SUITE 9055
PITTSBURGH PA
15213-2536
US

V. Phone/Fax

Practice location:
  • Phone: 412-692-7932
  • Fax: 412-692-7939
Mailing address:
  • Phone: 412-647-3087
  • Fax: 412-647-4486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD419882
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberMD419882
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: