Provider Demographics
NPI:1386642379
Name:CANNELLA, JOHN J (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:CANNELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:729 N CUSTER AVE
Mailing Address - Street 2:P.O. BOX 2339
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-4311
Mailing Address - Country:US
Mailing Address - Phone:308-382-9266
Mailing Address - Fax:308-382-5290
Practice Address - Street 1:729 N CUSTER AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-4311
Practice Address - Country:US
Practice Address - Phone:308-382-9266
Practice Address - Fax:308-382-5290
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12464207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01707OtherBCBS INDIVIDUAL #
NE47059252300Medicaid
NE01707OtherBCBS INDIVIDUAL #
NED05093Medicare UPIN
NE110073160Medicare ID - Type UnspecifiedRR MEDICARE INDIVIDUAL #