Provider Demographics
NPI:1851570741
Name:BRIAN G. CANNON, MD
Entity Type:Organization
Organization Name:BRIAN G. CANNON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-226-0267
Mailing Address - Street 1:2 FON CLAIR TER
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095-3100
Mailing Address - Country:US
Mailing Address - Phone:518-226-0267
Mailing Address - Fax:518-587-0238
Practice Address - Street 1:2 FON CLAIR TER
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:NY
Practice Address - Zip Code:12095-3100
Practice Address - Country:US
Practice Address - Phone:518-226-0267
Practice Address - Fax:518-587-0238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1314Medicare PIN
NYDD2256Medicare PIN