1265405468 NPI number — DR. STEPHANIE L. RUSS-BARBER MD

Table of content: DR. STEPHANIE L. RUSS-BARBER MD (NPI 1265405468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265405468 NPI number — DR. STEPHANIE L. RUSS-BARBER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSS-BARBER
Provider First Name:
STEPHANIE
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1265405468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 DICK LONAS RD UNIT 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37909-1383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-500-2144
Provider Business Mailing Address Fax Number:
865-584-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2587 WILLOW POINT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37931-3162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-470-2560
Provider Business Practice Location Address Fax Number:
865-691-5883
Provider Enumeration Date:
02/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  051725 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: TL28480 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 48935 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 085003062G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q000722 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".