Provider Demographics
NPI:1982656328
Name:CONRAD, STACEY SCOT (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:SCOT
Last Name:CONRAD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 JENNINGS DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-9786
Mailing Address - Country:US
Mailing Address - Phone:317-575-8118
Mailing Address - Fax:
Practice Address - Street 1:8924 E 96TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9648
Practice Address - Country:US
Practice Address - Phone:317-841-2700
Practice Address - Fax:317-841-2733
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001084A111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100126630AMedicaid
IN000000092856OtherANTHEM PIN NUMBER
INT379969Medicare UPIN
IN100126630AMedicaid