Provider Demographics
NPI:1003221532
Name:CANNON SQUARE FAMILY CARE
Entity Type:Organization
Organization Name:CANNON SQUARE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:AUTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:828-292-3320
Mailing Address - Street 1:105A N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-3213
Mailing Address - Country:US
Mailing Address - Phone:828-291-3320
Mailing Address - Fax:828-241-2312
Practice Address - Street 1:105A N MAIN AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-3213
Practice Address - Country:US
Practice Address - Phone:828-291-3320
Practice Address - Fax:828-241-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34551207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356321038OtherINDIVIDUAL NPI
NC8912241Medicaid
NC8912241Medicaid