Provider Demographics
NPI:1093079402
Name:CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC
Entity Type:Organization
Organization Name:CANNON PLASTIC & RECONSTRUCTIVE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:L
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:912-354-7044
Mailing Address - Street 1:PO BOX 15878
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-2578
Mailing Address - Country:US
Mailing Address - Phone:912-354-7044
Mailing Address - Fax:912-355-3066
Practice Address - Street 1:5205 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4501
Practice Address - Country:US
Practice Address - Phone:912-354-7044
Practice Address - Fax:912-355-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty