Healthcare Provider Details

I. General information

NPI: 1750336863
Provider Name (Legal Business Name): CHARLES W SCOWCROFT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEDICAL CENTER DR STE 308
PADUCAH KY
42003-7915
US

IV. Provider business mailing address

225 MEDICAL CENTER DR STE 308
PADUCAH KY
42003-7915
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-0777
  • Fax: 270-443-0999
Mailing address:
  • Phone: 270-443-0777
  • Fax: 270-443-0999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number11819
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberTP500
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: