Provider Demographics
NPI:1750304135
Name:CANNON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CANNON MEMORIAL HOSPITAL
Other - Org Name:CANNON FAMILY PRACTICE - LIBERTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-898-1133
Mailing Address - Street 1:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-897-8280
Mailing Address - Fax:864-897-8281
Practice Address - Street 1:105 LIBERTY BLVD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:SC
Practice Address - Zip Code:29657-1641
Practice Address - Country:US
Practice Address - Phone:864-843-9213
Practice Address - Fax:864-843-5634
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANNON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-26
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2510Medicaid
SC6308Medicare PIN