Provider Demographics
NPI:1033182043
Name:CANNON, JIMMIE DALE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:DALE
Last Name:CANNON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:275 COLLIER ROAD, NW
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1711
Mailing Address - Country:US
Mailing Address - Phone:404-605-2800
Mailing Address - Fax:404-351-5983
Practice Address - Street 1:220 J.L. WHITE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4894
Practice Address - Country:US
Practice Address - Phone:706-253-8001
Practice Address - Fax:706-253-8002
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-10-01
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Provider Licenses
StateLicense IDTaxonomies
SC14897207RC0000X
GA072875207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC060021300OtherPTAN
SC148977Medicaid
SCC30400Medicare PIN
F10490Medicare UPIN
SCAA41660281Medicare PIN
SC148977Medicaid