Basic Information
| Provider Information | |||||||||
| NPI: | 1710928379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANON | ||||||||
| FirstName: | CHERI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55310 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057319701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 19TH STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059344011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 19302 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 009937021 | 05 | AL | MEDICAID | 051505897 | 01 | AL | BCBS | OTHER | 051512192 | 01 | AL | BCBS | OTHER | 051534539 | 01 | AL | BCBS | OTHER | 010033CG73405 | 01 | AL | SECTION 1011 | OTHER | G73405 | 01 | VIVA | OTHER | 76770 | 01 | AL | BCBS | OTHER | 000076770 | 05 | AL | MEDICAID | G73405 | 01 | AL | VIVA | OTHER |