Provider Demographics
NPI:1124132386
Name:CANNON, BRETT H (MD)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:H
Last Name:CANNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 NEW NORTHSIDE DR NW
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:770-874-5400
Mailing Address - Fax:770-874-5469
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-920-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046053207P00000X
VA0101236067207P00000X
NC200301097207P00000X
LA15230R207P00000X
ALMD.25283207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00866115IMedicaid
GA00866115KMedicaid
GA00866115JMedicaid
AL051559698Medicaid
AL7559160OtherAETNA
GA00866115LMedicaid
AL051542477OtherBCBS
AL7559160OtherAETNA
GA93BDNZHMedicare ID - Type UnspecifiedMEDICARE COBB
GA00866115LMedicaid
AL051559698Medicare PIN
GAH14388Medicare UPIN
AL051559698Medicaid