Provider Demographics
NPI:1952368136
Name:CANNON, JEREMY WYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WYNNE
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:51 N 39TH STREET
Mailing Address - Street 2:SUITE 120 MOB
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-7323
Mailing Address - Fax:215-243-4679
Practice Address - Street 1:51 N 39TH STREET
Practice Address - Street 2:SUITE 120 MOB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-7323
Practice Address - Fax:215-243-4679
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-29
Last Update Date:2022-06-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4545302086S0102X, 2086S0127X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care