1164508198 NPI number — STEPHANIE M. RUSSELL MD PSC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164508198 NPI number — STEPHANIE M. RUSSELL MD PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHANIE M. RUSSELL MD PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KIDZLIFE PEDIATRICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164508198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10639 MEETING STREET
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
PROSPECT
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40059-7544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-425-7827
Provider Business Mailing Address Fax Number:
502-412-3979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10639 MEETING STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PROSPECT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40059-7544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-425-7827
Provider Business Practice Location Address Fax Number:
502-412-3979
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-425-7827

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200314560A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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