MEDICARE: DR. TIMOTHY L CANNIS 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	207P00000X	Emergency Medicine Physician	G034939	CA

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	:	1659373652
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY L CANNIS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 28247
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85285-8247
Country	:	US
Telephone Number	:	480-967-6500
Fax Number	:	480-967-6540

Provider Business Practice Location Address
First Line	:	3434 MIDWAY DR
Second Line	:	STE 1002
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4923
Country	:	US
Telephone Number	:	619-225-6200
Fax Number	:	619-225-6208

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	09/28/2010

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