Provider Demographics
NPI:1760685143
Name:CANNON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:CANNON MEMORIAL HOSPITAL
Other - Org Name:CANNON FAMILY PRACTICE - EASTSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:RENTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-878-4791
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-0919
Mailing Address - Country:US
Mailing Address - Phone:864-897-8286
Mailing Address - Fax:864-897-8281
Practice Address - Street 1:111 W. ROPER RD.
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640
Practice Address - Country:US
Practice Address - Phone:864-897-8280
Practice Address - Fax:864-897-8281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANNON MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-06
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4650Medicaid
SC5664Medicare PIN