Provider Demographics
NPI:1700831617
Name:KANOVITZ, BOB S (MD)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:S
Last Name:KANOVITZ
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 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:270-766-1222
Practice Address - Street 1:331 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1032
Practice Address - Country:US
Practice Address - Phone:502-348-9206
Practice Address - Fax:502-348-6485
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY141602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30605018Medicaid
KY343023OtherTRICARE
KY000000317338OtherANTHEM
11386231OtherCAQH
KY0762213Medicare ID - Type UnspecifiedMEDICARE
C69497Medicare UPIN
KY0763510Medicare ID - Type UnspecifiedMEDICARE
11386231OtherCAQH
KY0359281Medicare ID - Type UnspecifiedMEDICARE
KY0762310Medicare ID - Type UnspecifiedMEDICARE
KY0359083Medicare ID - Type UnspecifiedMEDICARE
0358983Medicare ID - Type Unspecified
KY0358781Medicare ID - Type UnspecifiedMEDICARE
KY30605018Medicaid
KY343023OtherTRICARE