Provider Demographics
NPI:1780648691
Name:GANNON, LIAM G (MD)
Entity Type:Individual
Prefix:
First Name:LIAM
Middle Name:G
Last Name:GANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100A MACDONOUGH DR
Mailing Address - Street 2:
Mailing Address - City:VERGENNES
Mailing Address - State:VT
Mailing Address - Zip Code:05491-1057
Mailing Address - Country:US
Mailing Address - Phone:802-877-0157
Mailing Address - Fax:
Practice Address - Street 1:100A MACDONOUGH DR
Practice Address - Street 2:
Practice Address - City:VERGENNES
Practice Address - State:VT
Practice Address - Zip Code:05491-1057
Practice Address - Country:US
Practice Address - Phone:802-877-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010022173000000X
VT042-0010022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN2298Medicaid
VTOVN2298Medicaid
VTOVN2298Medicaid
VTVN2298Medicare ID - Type UnspecifiedMEDICARE
VT0VN2298Medicaid