Provider Demographics
NPI:1740590983
Name:PATRICK J. CANNON, MD FACS A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PATRICK J. CANNON, MD FACS A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-788-5700
Mailing Address - Street 1:16101 VENTURA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2500
Mailing Address - Country:US
Mailing Address - Phone:818-788-5700
Mailing Address - Fax:818-788-5702
Practice Address - Street 1:16101 VENTURA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2500
Practice Address - Country:US
Practice Address - Phone:818-788-5700
Practice Address - Fax:818-788-5702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-20
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29054208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA91170Medicare UPIN