=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861497661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE AVERY KONDIK PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2005
-----------------------------------------------------
Last Update Date | 05/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2845 CHANCELLOR DR
-----------------------------------------------------
City | CRESTVIEW HILLS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41017-3418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-426-4200
-----------------------------------------------------
Fax | 859-426-4206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 560 S LOOP RD
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41017-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-301-2663
-----------------------------------------------------
Fax | 859-301-0655
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA568
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------