MEDICARE: MR. HAROLD C CANNON JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	01036413A	IN
2	174400000X	Specialist	22288	KY
3	207T00000X	Neurological Surgery Physician	22288	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000388450	OTHER	KY	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063415826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HAROLD C CANNON JR. MD

Provider Business Mailing Address
First Line	:	2200 E PARRISH AVE
Second Line	:	BLDG D SUITE 100
City	:	OWENSBORO
State	:	KY
Zip	:	42303-1449
Country	:	US
Telephone Number	:	270-688-1770
Fax Number	:	270-688-1780

Provider Business Practice Location Address
First Line	:	2200 E PARRISH AVE
Second Line	:	BLDG D SUITE 100
City	:	OWENSBORO
State	:	KY
Zip	:	42303-1449
Country	:	US
Telephone Number	:	270-688-1770
Fax Number	:	270-688-1780

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	07/08/2013

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Directions to “ MR. HAROLD C CANNON JR. MD” Practice Location

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