Provider Demographics
NPI:1528060043
Name:TANOUS, EDWARD J JR (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:TANOUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3529 SOLUTIONS CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-3005
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:175 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1169
Practice Address - Country:US
Practice Address - Phone:859-745-3500
Practice Address - Fax:859-737-8350
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25971207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64259716Medicaid
KYF27727Medicare UPIN
KY2587Medicare PIN
KY0258702Medicare PIN
KY64259716Medicaid