1831408046 NPI number — C. CRAIG STAFFORD, MD PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831408046 NPI number — C. CRAIG STAFFORD, MD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
C. CRAIG STAFFORD, MD PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831408046
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 HARRODSBURG RD
Provider Second Line Business Mailing Address:
BLDG A STE 450
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40504-3751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-373-0215
Provider Business Mailing Address Fax Number:
859-373-0235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 HARRODSBURG ROAD
Provider Second Line Business Practice Location Address:
A-450
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-3794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-373-0215
Provider Business Practice Location Address Fax Number:
859-373-0235
Provider Enumeration Date:
10/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
STAFFORD
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
CRAIG
Authorized Official Title or Position:
OWNER/MD
Authorized Official Telephone Number:
859-373-0215

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  24728 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 3004939 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100143740 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100144720 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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