Provider Demographics
NPI:1346287042
Name:GANNON, JENNIFER BOTTE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOTTE
Last Name:GANNON
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:MOUNT KISCO MEDICAL GROUP PC
Mailing Address - Street 2:90 SOUTH BEDFORD ROAD
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3412
Mailing Address - Country:US
Mailing Address - Phone:914-241-1050
Mailing Address - Fax:914-242-1516
Practice Address - Street 1:MOUNT KISCO MEDICAL GROUP PC
Practice Address - Street 2:90 SOUTH BEDFORD RD
Practice Address - City:MOUNT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3412
Practice Address - Country:US
Practice Address - Phone:914-241-1050
Practice Address - Fax:914-242-1516
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY236273207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02681029Medicaid
NYP00413158OtherMEDICARE RAILROAD
NY0667910001OtherDME
NY777E306761Medicare PIN