Provider Demographics
NPI:1164400842
Name:CANNON, JOSEPH M (MD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:M
Last Name:CANNON
Suffix:
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 1:22281 US HWY 72 E
Mailing Address - Street 2:SUITE B AND C
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613
Mailing Address - Country:US
Mailing Address - Phone:256-233-2158
Mailing Address - Fax:256-230-6825
Practice Address - Street 1:22281 US HWY 72 E
Practice Address - Street 2:SUITE B AND C
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613
Practice Address - Country:US
Practice Address - Phone:256-233-2158
Practice Address - Fax:256-230-6825
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL70092085B0100X, 2085N0700X, 2085P0229X, 2085R0202X, 2085R0203X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-33320OtherBLUE CROSS BLUE SHIELD OF AL (VIA: THE HEART CENTER)
ALCA009904395Medicaid
AL09936176Medicaid
AL515-33320OtherBLUE CROSS BLUE SHIELD OF AL (VIA: THE HEART CENTER)
AL6178180001Medicare NSC
AL051533320Medicare PIN
AL000039028Medicare UPIN
AL09936176Medicaid