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General NPI Number Information
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NPI Number | 1851570741
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Entity Type | Organization
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Legal Business Name | BRIAN G. CANNON, MD
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Dates
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Enumeration Date | 10/29/2007
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Last Update Date | 10/29/2007
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Provider Practice Location Address
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Address Line | 2 FON CLAIR TER
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City | JOHNSTOWN
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State | NY
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Zip | 12095-3100
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Country | US
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Telephone | 518-226-0267
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Fax | 518-587-0238
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Provider Business Mailing Address
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Address Line | 2 FON CLAIR TER
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City | JOHNSTOWN
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State | NY
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Zip | 12095-3100
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Country | US
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Telephone | 518-226-0267
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Fax | 518-587-0238
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. BRIAN G CANNON
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Credential | MD
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Telephone | 518-226-0267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 125142
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License Number State | NY
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