MEDICARE: DR. STACY REBECCA CONRAD OD

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	152W00000X	Optometrist	1976	TN
2	152W00000X	Optometrist	1809	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3944233	OTHER	TN	PTAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902802176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY REBECCA CONRAD OD

Provider Business Mailing Address
First Line	:	8015 MILL CREEK RD
Second Line	:
City	:	SIGNAL MOUNTAIN
State	:	TN
Zip	:	37377-1734
Country	:	US
Telephone Number	:	423-886-9080
Fax Number	:

Provider Business Practice Location Address
First Line	:	5301 HIGHWAY 153
Second Line	:
City	:	HIXSON
State	:	TN
Zip	:	37343-4912
Country	:	US
Telephone Number	:	423-877-9990
Fax Number	:

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	04/13/2010

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