Provider Demographics
NPI:1639242613
Name:AUDUBON GI PSC
Entity Type:Organization
Organization Name:AUDUBON GI PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CANLAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-826-0002
Mailing Address - Street 1:PO BOX 1098
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-1098
Mailing Address - Country:US
Mailing Address - Phone:270-826-0002
Mailing Address - Fax:270-826-0003
Practice Address - Street 1:1413 NORTH ELM ST
Practice Address - Street 2:SUITE 105
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4266
Practice Address - Country:US
Practice Address - Phone:270-826-0002
Practice Address - Fax:270-826-0003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18731174400000X
KY38601207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000047502OtherBLUE CROSS BLUE SHIELD
KY64187313Medicaid
KY000000047502OtherBLUE CROSS BLUE SHIELD
KY7774Medicare PIN