MEDICARE: JON D KANNENSOHN 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	208000000X	Pediatrics Physician	35078034K	OH

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	:	1760583587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON D KANNENSOHN MD

Provider Business Mailing Address
First Line	:	24701 EUCLID AVE
Second Line	:
City	:	EUCLID
State	:	OH
Zip	:	44117-1714
Country	:	US
Telephone Number	:	440-974-4411
Fax Number	:	440-974-4173

Provider Business Practice Location Address
First Line	:	9000 MENTOR AVE STE 100
Second Line	:
City	:	MENTOR
State	:	OH
Zip	:	44060-4496
Country	:	US
Telephone Number	:	440-974-4411
Fax Number	:	440-974-4173

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/12/2011

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Directions to “ JON D KANNENSOHN MD” Practice Location

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