Healthcare Provider Details

I. General information

NPI: 1932100872
Provider Name (Legal Business Name): JOHN GANIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL VILLAGE DR
EDGEWOOD KY
41017-3403
US

IV. Provider business mailing address

PO BOX 18667
ERLANGER KY
41018-0667
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-2250
  • Fax: 859-572-2326
Mailing address:
  • Phone: 859-572-3617
  • Fax: 859-572-2326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01058778A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36022
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: