Provider Demographics
NPI:1750336863
Name:SCOWCROFT, CHARLES W (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:SCOWCROFT
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 1:225 MEDICAL CENTER DR STE 308
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7915
Mailing Address - Country:US
Mailing Address - Phone:270-443-0777
Mailing Address - Fax:270-443-0999
Practice Address - Street 1:225 MEDICAL CENTER DR STE 308
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7915
Practice Address - Country:US
Practice Address - Phone:270-443-0777
Practice Address - Fax:270-443-0999
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11819174400000X
KYTP500207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC118198Medicaid
SC5969Medicare PIN
SC118198Medicaid