MEDICARE: JOE RONALD CANNON

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	291U00000X	Clinical Medical Laboratory	E2498	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	CL0449	OTHER	TX	BLUE CROSS

General Provider Information

NPI Number	:	1073647962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOE RONALD CANNON

Provider Business Mailing Address
First Line	:	PO BOX 3611
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79604-3611
Country	:	US
Telephone Number	:	325-672-2162
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 ORANGE ST
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79601-4020
Country	:	US
Telephone Number	:	325-672-2162
Fax Number	:

Authorized Official
Title or Position	:	DERMATOPATHOLOGIST
Name	:	JOE R CANNON
Credential	:	MD
Telephone Number	:	325-672-2162

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	01/08/2010

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