MEDICARE: DR. WADE RANDOLPH TAYLOR DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		FL
2	207Q00000X	Family Medicine Physician	04993	KY

General Provider Information

NPI Number	:	1215425038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WADE RANDOLPH TAYLOR DO

Provider Business Mailing Address
First Line	:	PO BOX 23229
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42304-3229
Country	:	US
Telephone Number	:	270-688-1330
Fax Number	:	270-688-1338

Provider Business Practice Location Address
First Line	:	2211 MAYFAIR DR STE 101
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42301-4569
Country	:	US
Telephone Number	:	270-688-1352
Fax Number	:	270-683-4313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2018
Last Update Date	:	09/19/2022

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