Provider Demographics
NPI:1881960037
Name:GANNON, STEPHEN ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANDREW
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 1:300 MOUNT AUBURN ST STE 310
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5665
Mailing Address - Country:US
Mailing Address - Phone:617-497-1560
Mailing Address - Fax:617-497-1190
Practice Address - Street 1:300 MOUNT AUBURN ST STE 310
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5665
Practice Address - Country:US
Practice Address - Phone:617-497-1560
Practice Address - Fax:617-497-1190
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD15347207RC0000X, 207R00000X
390200000X
MA274883207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110146553AMedicaid