Healthcare Provider Details

I. General information

NPI: 1821759796
Provider Name (Legal Business Name): CANNON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 WG ACKER DR
PICKENS SC
29671-2739
US

IV. Provider business mailing address

PO BOX 100174
COLUMBIA SC
29202-3174
US

V. Phone/Fax

Practice location:
  • Phone: 864-878-4791
  • Fax:
Mailing address:
  • Phone: 864-878-4791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHON M HERRON
Title or Position: FINANCIAL DIRECTOR
Credential:
Phone: 864-898-1151