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General NPI Number Information
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NPI Number | 1619030327
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Entity Type | Individual
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Provider Name | JACK RUSSELL CANNON II M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 300 RIDGE MEDICAL PLAZA
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City | EDGEFIELD
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State | SC
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Zip | 29824-9986
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Country | US
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Telephone | 803-637-1175
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Fax |
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Provider Business Mailing Address
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Address Line | 3510 AUGUSTUS RD
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City | AIKEN
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State | SC
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Zip | 29801-2702
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Country | US
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Telephone | 803-649-7706
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 9533
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License Number State | SC
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