Provider Demographics
NPI:1982667713
Name:CARMODY, PADRAIC C (MD)
Entity Type:Individual
Prefix:
First Name:PADRAIC
Middle Name:C
Last Name:CARMODY
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 1:5044 WHIPPOORWILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4526
Mailing Address - Country:US
Mailing Address - Phone:269-372-2846
Mailing Address - Fax:
Practice Address - Street 1:3125 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-2997
Practice Address - Country:US
Practice Address - Phone:269-372-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53739208600000X
MI4301053739208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102592947Medicaid
MI2592949Medicaid
MI0391064Medicare ID - Type Unspecified
MI102592947Medicaid