MEDICARE: CODY CONRAD

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	2255A2300X	Athletic Trainer		IN

General Provider Information

NPI Number	:	1043757743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY CONRAD

Provider Business Mailing Address
First Line	:	9611 TRENTMAN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-3233
Country	:	US
Telephone Number	:	260-602-4950
Fax Number	:

Provider Business Practice Location Address
First Line	:	9611 TRENTMAN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-3233
Country	:	US
Telephone Number	:	260-602-4950
Fax Number	:

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

Provider Enumeration Date	:	01/19/2017
Last Update Date	:	01/19/2017

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Directions to “ CODY CONRAD ” Practice Location

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