Provider Demographics
NPI:1487649448
Name:KANIA, GARY R (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:KANIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33650 HIGHWAY 43
Mailing Address - Street 2:SUITE100
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-3305
Mailing Address - Country:US
Mailing Address - Phone:334-636-9999
Mailing Address - Fax:334-636-9950
Practice Address - Street 1:33650 HIGHWAY 43
Practice Address - Street 2:SUITE100
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-3305
Practice Address - Country:US
Practice Address - Phone:334-636-9999
Practice Address - Fax:334-636-9950
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2010-12-06
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
ALDO-342208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000086382Medicaid
ALE49722Medicare UPIN
AL000086382Medicare ID - Type Unspecified