1710928379 NPI number — CHERI L CANON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710928379 NPI number — CHERI L CANON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANON
Provider First Name:
CHERI
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710928379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 55310
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35255
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-731-9701
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
619 19TH STREET SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-934-4011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  19302 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 009937021 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051505897 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051512192 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051534539 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 010033CG73405 . This is a "SECTION 1011" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: G73405 . This is a "VIVA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 76770 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000076770 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: G73405 . This is a "VIVA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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