Provider Demographics
NPI:1568521425
Name:KANOUSE, GARY DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DOUGLAS
Last Name:KANOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 E 16TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-2320
Mailing Address - Country:US
Mailing Address - Phone:570-752-5500
Mailing Address - Fax:570-752-6790
Practice Address - Street 1:695 E 16TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-2320
Practice Address - Country:US
Practice Address - Phone:570-752-5500
Practice Address - Fax:570-752-6790
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036479E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011256360001Medicaid
PA161376OtherHIGHMARK BLUE SHIELD
PA50002681OtherCAPITAL BLUE CROSS
PA0011256360001Medicaid
161376Medicare ID - Type Unspecified