MEDICARE: CHAD MICHAEL 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	207L00000X	Anesthesiology Physician	26477	OK

General Provider Information

NPI Number	:	1790947083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD MICHAEL CANNON M.D.

Provider Business Mailing Address
First Line	:	P.O. BOX 235019
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36123-5019
Country	:	US
Telephone Number	:	800-232-5703
Fax Number	:	918-748-7688

Provider Business Practice Location Address
First Line	:	8131 S. MEMORIAL DRIVE
Second Line	:	SUITE 107
City	:	TULSA
State	:	OK
Zip	:	74133-4348
Country	:	US
Telephone Number	:	918-252-5114
Fax Number	:	918-748-7688

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

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	03/25/2020

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