Basic Information
| Provider Information | |||||||||
| NPI: | 1881805265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DRIVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1854 W AUBURN RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483093868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488532323 | ||||||||
| FaxNumber: | 2488538890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 206201 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 4301061767 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1881805265 | 05 | MI | MEDICAID |