Healthcare Provider Details

I. General information

NPI: 1134161110
Provider Name (Legal Business Name): GARY R CONRAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST HX318
LEXINGTON KY
40536-0293
US

IV. Provider business mailing address

800 ROSE ST HX318
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5069
  • Fax:
Mailing address:
  • Phone: 859-323-5069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number26309
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26309
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: