MEDICARE: MR. HARVEY R CRADDOCK SURGICAL ASSISTANT

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	246ZS0410X	Surgical Technologist	SA011	KY

General Provider Information

NPI Number	:	1902822844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HARVEY R CRADDOCK SURGICAL ASSISTANT

Provider Business Mailing Address
First Line	:	PO BOX 6292
Second Line	:
City	:	ELIZABETHTOWN
State	:	KY
Zip	:	42702-6292
Country	:	US
Telephone Number	:	270-317-4827
Fax Number	:	270-234-8558

Provider Business Practice Location Address
First Line	:	258 CORVIN LN
Second Line	:
City	:	ELIZABETHTOWN
State	:	KY
Zip	:	42701-5771
Country	:	US
Telephone Number	:	270-317-4827
Fax Number	:	270-234-8558

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

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	02/07/2008

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