MEDICARE: STANFORD WELLCARE CLINIC PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	363A00000X	Physician Assistant
3	363L00000X	Nurse Practitioner
4	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1861071219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANFORD WELLCARE CLINIC PLLC

Provider Business Mailing Address
First Line	:	132 FRONTIER BLVD STE 101
Second Line	:
City	:	STANFORD
State	:	KY
Zip	:	40484-6516
Country	:	US
Telephone Number	:	606-727-5757
Fax Number	:	606-727-5777

Provider Business Practice Location Address
First Line	:	132 FRONTIER BLVD STE 101
Second Line	:
City	:	STANFORD
State	:	KY
Zip	:	40484-6516
Country	:	US
Telephone Number	:	606-727-5757
Fax Number	:	606-727-5777

Authorized Official
Title or Position	:	OWNER
Name	:	IMAD A HADDAD
Credential	:	MD
Telephone Number	:	859-481-7113

Provider Enumeration Date	:	04/05/2021
Last Update Date	:	08/03/2021

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