Provider Demographics
NPI:1467533257
Name:S. CANNON MEDICAL P.A.
Entity Type:Organization
Organization Name:S. CANNON MEDICAL P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:PECKINPAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-938-4886
Mailing Address - Street 1:2402 S. CANNON BLVD.
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083
Mailing Address - Country:US
Mailing Address - Phone:704-938-4886
Mailing Address - Fax:704-938-5644
Practice Address - Street 1:2402 S. CANNON BLVD.
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083
Practice Address - Country:US
Practice Address - Phone:704-938-4886
Practice Address - Fax:704-938-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8966442Medicaid
NC0189FOtherBLUE CROSS
NC890189FMedicaid
2148768CMedicare PIN
2314592Medicare ID - Type Unspecified
NC8966442Medicaid