Basic Information
| Provider Information | |||||||||
| NPI: | 1134206634 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 W JEFFERSON ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461319120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177368474 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 W JEFFERSON ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461319120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177368474 | ||||||||
| FaxNumber: | 3177366040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01023878 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100220010 | 05 | IN | MEDICAID |