Healthcare Provider Details

I. General information

NPI: 1780648691
Provider Name (Legal Business Name): LIAM G. GANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100A MACDONOUGH DR
VERGENNES VT
05491-1057
US

IV. Provider business mailing address

100A MACDONOUGH DR
VERGENNES VT
05491-1057
US

V. Phone/Fax

Practice location:
  • Phone: 802-877-0157
  • Fax:
Mailing address:
  • Phone: 802-877-0157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number0420010022
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-0010022
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: