Provider Demographics
NPI:1043372089
Name:CANNON FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:CANNON FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-783-5900
Mailing Address - Street 1:719 N EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-3856
Mailing Address - Country:US
Mailing Address - Phone:337-783-5900
Mailing Address - Fax:337-783-5914
Practice Address - Street 1:719 N EASTERN AVE
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-3856
Practice Address - Country:US
Practice Address - Phone:337-783-5900
Practice Address - Fax:337-783-5914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1048577Medicaid
H68168Medicare UPIN
LA1048577Medicaid