Provider Demographics
NPI:1831408046
Name:C. CRAIG STAFFORD, MD PSC
Entity type:Organization
Organization Name:C. CRAIG STAFFORD, MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-373-0215
Mailing Address - Street 1:1401 HARRODSBURG RD
Mailing Address - Street 2:BLDG A STE 450
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3751
Mailing Address - Country:US
Mailing Address - Phone:859-373-0215
Mailing Address - Fax:859-373-0235
Practice Address - Street 1:1401 HARRODSBURG ROAD
Practice Address - Street 2:A-450
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3794
Practice Address - Country:US
Practice Address - Phone:859-373-0215
Practice Address - Fax:859-373-0235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004939363L00000X
KY24728207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100143740Medicaid
KY7100144720Medicaid
KY7100143740Medicaid