Basic Information
| Provider Information | |||||||||
| NPI: | 1700831617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANOVITZ | ||||||||
| FirstName: | BOB | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 CRANES ROOST CT | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427013650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652605 | ||||||||
| FaxNumber: | 2707661222 | ||||||||
| Practice Location | |||||||||
| Address1: | 331 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BARDSTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400041032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023489206 | ||||||||
| FaxNumber: | 5023486485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 14160 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 30605018 | 05 | KY | MEDICAID | 343023 | 01 | KY | TRICARE | OTHER | 000000317338 | 01 | KY | ANTHEM | OTHER | 11386231 | 01 | CAQH | OTHER |