Cannon Memorial Hospital
Organization Active NPI Rural Health Clinic/Center · Liberty, SC
NPI 1902224876 · NPPES record last updated Jun 21, 2023
Key facts
- NPI
- 1902224876
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- CANNON MEMORIAL HOSPITAL
- Practice address
- 105 Liberty Blvd
Liberty, SC 29657-1641 - Phone
- (864) 843-9213
- Fax
- (864) 843-5634
- NPI assigned
- Mar 28, 2014
- Organization subpart
- Yes
- Parent organization (as reported)
- CANNON MEMORIAL HOSPITAL
Authorized official
- Name
- Michael Cunningham
- Title
- Ceo
- Phone
- (864) 898-1133
Owners & managing parties with NPI records 3
Owned or controlled facilities with NPI records 2
Other NPIs with the same Medicare PAC ID 3
Corporate family (same tax ID) 12
Member organizations 1
Related certifications (CCN) 1
Facilities with the same owner 2
Practitioners 30
-
Zahid Ali, MD
-
Aftab A Awan, MD
-
Stacy Browder, FNP-BC
-
James Clifton Caldwell, M.D.
-
Michael L Dillard, M.D.
-
Lori Kaye Ellenburg, APRN
-
Matthew John Flood, M.D.
-
Augusta B Hall, FNP - C
-
Jill Heatherington, FNP-C
-
Trang D Lusk, APRN, BC
-
Deanna McGee, APRN
-
Robert Goodwin Person, M.D.
-
Thomas Richard Prostko, M.D.
-
Yashbir S Rana, MD
-
John Randolph, M.D.
-
Glenda G. Snyder, NP
-
Heather Renee Turner, FNP-BC
-
Karen Weise, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in SC
Rural health clinic certification: CCN 423462
- Legal name
- CANNON MEMORIAL HOSPITAL
- Doing business as
- ANMED PRIMARY CARE - LIBERTY
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Mar 29, 2018
- Last certification
- Sep 12, 2023
- Ownership / control type
- 2B
- Organization structure
- Corporation · Non-profit
- Incorporated
- Dec 27, 1950 in SC
- Enrollment address
- 105 Liberty Blvd
Liberty, SC 29657-1641 - Related CCNs
- 420011
All disclosed owners & managing parties 9
| Name | Role | Since | Share |
|---|---|---|---|
| Linda Cassell |
Corporate Officer |
Jan 1, 2011 | |
| Stephen J Grigsby |
Corporate Director | Apr 28, 2025 | |
| Robert Bradley Mock |
Corporate Officer |
Jan 1, 2019 | |
| Michael Cunningham |
Corporate Officer |
Jun 1, 2021 | |
| W-2 Managing Employee |
Jun 1, 2021 | ||
| Harold Alexander |
Corporate Director | Feb 28, 2022 | |
| Zachary Hinton |
Corporate Officer |
Mar 25, 2019 | |
| William Kenley |
Corporate Officer |
Sep 21, 2020 | |
| Corporate Director |
Sep 21, 2020 | ||
| W-2 Managing Employee |
Sep 21, 2020 | ||
| Scott Wesikittle |
Corporate Director | Aug 29, 2022 | |
| Cannon Memorial Hospital |
5% Or Greater Direct Ownership Interest | Jan 1, 2014 | 100% |
| Operational/Managerial Control | Jan 1, 2014 | 100% |
All facility ownership & control disclosures 2
| Facility | Type | Role | Since |
|---|---|---|---|
| Anmed Cannon |
Hospital | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control (100%) |
Jan 1, 2014 Jan 1, 2014 |
| Anmed Primary Care - Easley |
Rural health clinic | 5% Or Greater Direct Ownership Interest (100%) Operational/Managerial Control (100%) |
Jan 1, 2014 Jan 1, 2014 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20170420002725 | SC | Part a Provider - Rural Health Clinic | 8123930666 | Practice locations: Liberty, SC |
National Provider Directory
- Tax ID family
- Cannon Memorial Hospital
- Part of
- Cannon Memorial Hospital
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
105 Liberty Blvd
Liberty, SC 29657-1641
Mailing address
PO Box 100174
Columbia, SC 29202-3174
Phone (864) 897-8286
Other names
- AnMed Primary Care - Liberty
Other providers in Liberty, SC
- Bright Smile Center - Liberty, PA
- Stacy Browder
- Robert Mason Burdine Jr.
- Brian Michael Burton
- Cannon Memorial Hospital
- Lynn Melton Capobianco
- Sara Lynn Carlstrom
- Lori R Carnsew
- Cole-McGill Enterprises
- Cole-McGill Enterprises Inc
All providers in Liberty, SC · Rural Health Clinic/Center in South Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 21, 2023. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.