Basic Information
| Provider Information | |||||||||
| NPI: | 1518614346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONRAD | ||||||||
| FirstName: | MADELINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7933 SCHOOL HOUSE LN | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452425928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132358258 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10500 MONTGOMERY RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452424402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138651111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2022 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.007495RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0462231 | 05 | OH | MEDICAID |