Healthcare Provider Details

I. General information

NPI: 1639242613
Provider Name (Legal Business Name): AUDUBON GI PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1413 NORTH ELM ST SUITE 105
HENDERSON KY
42420-4266
US

IV. Provider business mailing address

PO BOX 1098
HENDERSON KY
42419-1098
US

V. Phone/Fax

Practice location:
  • Phone: 270-826-0002
  • Fax: 270-826-0003
Mailing address:
  • Phone: 270-826-0002
  • Fax: 270-826-0003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number38601
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number18731
License Number StateKY

VIII. Authorized Official

Name: DR. KAREN R. CANLAS
Title or Position: PRESIDENT
Credential: MD
Phone: 270-826-0002