MEDICARE: DR. GARY DOUGLAS KANOUSE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD036479E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	161376	OTHER	PA	HIGHMARK BLUE SHIELD
3	50002681	OTHER	PA	CAPITAL BLUE CROSS

General Provider Information

NPI Number	:	1568521425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY DOUGLAS KANOUSE M.D.

Provider Business Mailing Address
First Line	:	695 E 16TH ST
Second Line	:	SUITE D
City	:	BERWICK
State	:	PA
Zip	:	18603-2320
Country	:	US
Telephone Number	:	570-752-5500
Fax Number	:	570-752-6790

Provider Business Practice Location Address
First Line	:	695 E 16TH ST
Second Line	:	SUITE D
City	:	BERWICK
State	:	PA
Zip	:	18603-2320
Country	:	US
Telephone Number	:	570-752-5500
Fax Number	:	570-752-6790

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2006
Last Update Date	:	07/08/2007

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