Provider Demographics
NPI:1386867190
Name:STAMPING GROUND FAMILY CLINIC
Entity Type:Organization
Organization Name:STAMPING GROUND FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CEDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-535-5686
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:STAMPING GROUND
Mailing Address - State:KY
Mailing Address - Zip Code:40379-0179
Mailing Address - Country:US
Mailing Address - Phone:502-535-5686
Mailing Address - Fax:
Practice Address - Street 1:3501 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STAMPING GROUND
Practice Address - State:KY
Practice Address - Zip Code:40379-0179
Practice Address - Country:US
Practice Address - Phone:502-535-5686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty