Basic Information
Provider Information | |||||||||
NPI: | 1962498113 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARNEAU | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2421 BROADWAY ST | ||||||||
Address2: |   | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420017115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704428272 | ||||||||
FaxNumber: | 2704440539 | ||||||||
Practice Location | |||||||||
Address1: | 2725 JAMES SANDERS BLVD STE A | ||||||||
Address2: |   | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420018405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2705545114 | ||||||||
FaxNumber: | 2702154834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2005 | ||||||||
LastUpdateDate: | 05/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 27794 | KY | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 64277940 | 05 | KY |   | MEDICAID | 64377940 | 05 | KY |   | MEDICAID |