Provider Demographics
NPI:1194852392
Name:CANNON, PHILIP JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:JOHN
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1466 PEACHTREE BATTLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1426
Mailing Address - Country:US
Mailing Address - Phone:678-442-3317
Mailing Address - Fax:678-442-4416
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7694
Practice Address - Country:US
Practice Address - Phone:678-442-3317
Practice Address - Fax:678-442-4416
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029853207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00361292EMedicaid
GA00361292EMedicaid