Basic Information
| Provider Information | |||||||||
| NPI: | 1861497661 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KONDIK | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | AVERY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8593010655 | ||||||||
| Practice Location | |||||||||
| Address1: | 2845 CHANCELLOR DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594264200 | ||||||||
| FaxNumber: | 8594264206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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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 | 363AS0400X | PA568 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | CB8861 | 01 | KY | RAILROAD MEDICARE | OTHER | 000000241201 | 01 | KY | ANTHEM | OTHER | 90008962 | 01 | KY | MEDICAID DME | OTHER | 970027844 | 01 | KY | RAILROAD MEDICARE | OTHER | 428850003 | 01 | KY | MEDICARE DME | OTHER | 95001970 | 05 | KY | MEDICAID |