=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396067971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN CANNON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2010
-----------------------------------------------------
Last Update Date | 02/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1037 MAIN ST
-----------------------------------------------------
City | LEICESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01524-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-892-1335
-----------------------------------------------------
Fax | 508-892-1780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1037 MAIN ST
-----------------------------------------------------
City | LEICESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01524-1313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-892-1335
-----------------------------------------------------
Fax | 508-892-1780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5293
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------