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NPI Code Detail

MEDICARE: CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC

MEDICARE: CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC
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
1208200000XPlastic Surgery Physician

General Provider Information

NPI Number : 1093079402
Entity Type Code : Organization
Provider Name (Legal Business Name) : CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC
Provider Business Mailing Address
First Line : PO BOX 15878
Second Line :
City : SAVANNAH
State : GA
Zip : 31416-2578
Country : US
Telephone Number : 912-354-7044
Fax Number : 912-355-3066
Provider Business Practice Location Address
First Line : 5205 FREDERICK ST
Second Line :
City : SAVANNAH
State : GA
Zip : 31405-4501
Country : US
Telephone Number : 912-354-7044
Fax Number : 912-355-3066
Authorized Official
Title or Position : PRESIDENT
Name : CLIFTON L CANNON III
Credential : MD
Telephone Number : 912-354-7044
Provider Enumeration Date : 06/29/2012
Last Update Date : 11/19/2012

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Directions to “CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC ” Practice Location

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