Provider Demographics
NPI:1548529902
Name:GANNON, ROAN SUMNER (MD)
Entity type:Individual
Prefix:DR
First Name:ROAN
Middle Name:SUMNER
Last Name:GANNON
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 1:5104 US HIGHWAY 431
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-0237
Mailing Address - Country:US
Mailing Address - Phone:256-878-8180
Mailing Address - Fax:256-891-3693
Practice Address - Street 1:5104 US HIGHWAY 431
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-0237
Practice Address - Country:US
Practice Address - Phone:256-878-8180
Practice Address - Fax:256-891-3693
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL33074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program