Provider Demographics
NPI:1154414548
Name:HADLEY, FRED PARK (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:PARK
Last Name:HADLEY
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 1:1401 HARRODSBURG RD
Mailing Address - Street 2:STE C215
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-258-6450
Mailing Address - Fax:859-258-6499
Practice Address - Street 1:1401 HARRODSBURG RD
Practice Address - Street 2:STE C215
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3751
Practice Address - Country:US
Practice Address - Phone:859-258-6450
Practice Address - Fax:859-258-6499
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19048208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64190481Medicaid
C66968Medicare UPIN
KYP00381362Medicare PIN
KY0169Medicare PIN
KY64190481Medicaid