Provider Demographics
NPI:1528345741
Name:MICHAEL KANNER MD PA
Entity type:Organization
Organization Name:MICHAEL KANNER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:305-937-2020
Mailing Address - Street 1:4651 SHERIDAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3459
Mailing Address - Country:US
Mailing Address - Phone:954-894-1500
Mailing Address - Fax:954-894-1526
Practice Address - Street 1:4651 SHERIDAN ST STE 100
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3459
Practice Address - Country:US
Practice Address - Phone:954-894-1500
Practice Address - Fax:954-894-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0042160207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD79875Medicare UPIN
FL96286Medicare PIN