MEDICARE: SCOTT LAWRENCE CANNON M.D.

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	246Q00000X	Pathology Specialist/Technologist	3351	AK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	220030113	OTHER	AK	MEDICARE RR

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

General Provider Information

NPI Number	:	1164472742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT LAWRENCE CANNON M.D.

Provider Business Mailing Address
First Line	:	315 ILLINOIS ST
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99701-2910
Country	:	US
Telephone Number	:	907-456-7767
Fax Number	:	907-456-8050

Provider Business Practice Location Address
First Line	:	1650 COWLES ST
Second Line	:
City	:	FAIRBANKS
State	:	AK
Zip	:	99701-5925
Country	:	US
Telephone Number	:	907-458-5650
Fax Number	:	907-456-8050

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

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	12/09/2010

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Directions to “ SCOTT LAWRENCE CANNON M.D.” Practice Location

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