Basic Information
| Provider Information | |||||||||
| NPI: | 1750336863 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOWCROFT | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 MEDICAL CENTER DR STE 308 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704430777 | ||||||||
| FaxNumber: | 2704430999 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEDICAL CENTER DR STE 308 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704430777 | ||||||||
| FaxNumber: | 2704430999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11819 | SC | N | Other Service Providers | Specialist | 207RG0100X | TP500 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 118198 | 05 | SC | MEDICAID |