Provider Demographics
NPI:1205929478
Name:CANNON, CARRIE (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 EASTLAND AVE SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-4503
Mailing Address - Country:US
Mailing Address - Phone:330-746-9400
Mailing Address - Fax:330-746-9401
Practice Address - Street 1:4800 FRIENDSHIP AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1722
Practice Address - Country:US
Practice Address - Phone:412-578-5273
Practice Address - Fax:412-578-4934
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.083356208000000X
PAMD073333L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017486900002Medicaid
OH2556925Medicaid
OH2556925Medicaid
PA1017486900002Medicaid