Provider Demographics
NPI:1912990607
Name:PEDDICORD, CAROL B (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:B
Last Name:PEDDICORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25961207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64259617Medicaid
KYK126161Medicare PIN
KYK126161Medicare PIN