Provider Demographics
NPI:1053424010
Name:CARLOSS, HARRY WORTHINGTON (MD)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:WORTHINGTON
Last Name:CARLOSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MEDICAL CENTER DR STE 301
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7914
Mailing Address - Country:US
Mailing Address - Phone:270-441-4343
Mailing Address - Fax:270-441-4344
Practice Address - Street 1:225 MEDICAL CENTER DR STE 301
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-441-4343
Practice Address - Fax:270-441-4344
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18644174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64186448Medicaid
KY64186448Medicaid
KY1300701Medicare ID - Type UnspecifiedMEDICARE