Basic Information
| Provider Information | |||||||||
| NPI: | 1881960037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANNON | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 MOUNT AUBURN ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174971560 | ||||||||
| FaxNumber: | 6174971190 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MOUNT AUBURN ST STE 310 | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174971560 | ||||||||
| FaxNumber: | 6174971190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2012 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD15347 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | MD15347 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0000X | 274883 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 110146553A | 05 | MA | MEDICAID |