Provider Demographics
NPI:1952410961
Name:CANNON, CHAD M (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:M
Last Name:CANNON
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 1:2330 SHAWNEE MISSION PKWY
Mailing Address - Street 2:MEDICAL ADMINISTRATIVE SERVICES OF KU MED. STE 312
Mailing Address - City:WESTWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2005
Mailing Address - Country:US
Mailing Address - Phone:913-588-9800
Mailing Address - Fax:913-588-9822
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:PROFESSIONAL SERVICES OF KU HOSPITAL
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-0001
Practice Address - Country:US
Practice Address - Phone:913-588-6504
Practice Address - Fax:913-588-9104
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30528207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7041574OtherAETNA
P00182493OtherRR MEDICARE
10001707900OtherCHP PROVIDER NUMBER
33979012OtherBCBS PSKU
478140OtherFIRSTGUARD
33979012OtherBCBS PSKU
KSK40D244Medicare PIN