1356309942 NPI number — HERBERT H GANNON JR. MD

Table of content: HERBERT H GANNON JR. MD (NPI 1356309942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356309942 NPI number — HERBERT H GANNON JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANNON
Provider First Name:
HERBERT
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1356309942
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4300 WEST MAIN STREET
Provider Second Line Business Mailing Address:
STE 31
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36305-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-6511
Provider Business Mailing Address Fax Number:
334-677-5642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 WEST MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 31 WOMENS HEALTHCARE OF DOTHAN PC
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36305-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-6511
Provider Business Practice Location Address Fax Number:
334-677-5642
Provider Enumeration Date:
05/03/2006

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: 207VG0400X , with the licence number:  00006291 , 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: 000004270 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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