NPIMap

Organization Active NPI

Robert M Cannon MD LLC

  • Primary Care Clinic/Center
  • Vicksburg, MS
National Provider Identifier
1174067250
Registry record updated Dec 8, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
ROBERT M CANNON MD LLC
Practice address
1901 Mission 66
Vicksburg, MS 39180-3711
Phone
(601) 636-0097
Fax
(601) 629-9969
NPI assigned
Dec 8, 2016
Last updated
Dec 8, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 8, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert Cannon, MDNPI 1215373139
Title
MD
Phone
(601) 636-0097

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X NU Primary

Addresses

Primary practice location

1901 Mission 66
Vicksburg, MS 39180-3711

Mailing address

1901 Mission 66
Vicksburg, MS 39180-3711
Phone (601) 636-0097

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170214000363 MS Part B Supplier - Clinic/Group Practice 5890078067 Receives reassigned benefits from 1 practitioner
Practice locations: Vicksburg, MS

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1481155200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1481155200000",
    "number": "1174067250",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 MISSION 66",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391803711",
            "telephone_number": "601-636-0097",
            "fax_number": "601-629-9969"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1901 MISSION 66",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391803711",
            "telephone_number": "601-636-0097",
            "fax_number": "601-629-9969"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ROBERT M CANNON MD LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-12-08",
        "last_updated": "2016-12-08",
        "status": "A",
        "authorized_official_last_name": "CANNON",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_title_or_position": "MD",
        "authorized_official_telephone_number": "601-636-0097",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Vicksburg, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 8, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.