Individual
DR. JACK RUSSELL CANNON II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
300 RIDGE MEDICAL PLAZA, EDGEFIELD, SC 29824-9986
(803) 637-1175
Mailing address
3510 AUGUSTUS RD, AIKEN, SC 29801-2702
(803) 649-7706
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
9533
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
095332
—
SC
Enumeration date
12/18/2006
Last updated
07/09/2007
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