Provider Demographics
NPI:1760874713
Name:CAROL B PEDDICORD MD PLLC
Entity Type:Organization
Organization Name:CAROL B PEDDICORD MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDDICORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-688-4470
Mailing Address - Street 1:250 BURKESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:KY
Mailing Address - Zip Code:42602-1604
Mailing Address - Country:US
Mailing Address - Phone:606-387-0323
Mailing Address - Fax:606-387-0310
Practice Address - Street 1:250 BURKESVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1604
Practice Address - Country:US
Practice Address - Phone:606-387-0323
Practice Address - Fax:606-387-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-28
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK126160Medicare PIN
E60397Medicare UPIN
1280503Medicare PIN