Provider Demographics
NPI:1043366313
Name:CANNELLA, LOUIS JAMES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:JAMES
Last Name:CANNELLA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-2105
Mailing Address - Country:US
Mailing Address - Phone:906-863-8853
Mailing Address - Fax:
Practice Address - Street 1:2009 10TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-2105
Practice Address - Country:US
Practice Address - Phone:906-863-8853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301040183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4387698Medicaid
MI4387698Medicaid