1366869208 NPI number — ELIZABETH S STIVERS M.D.

Table of content: ELIZABETH S STIVERS M.D. (NPI 1366869208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366869208 NPI number — ELIZABETH S STIVERS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STIVERS
Provider First Name:
ELIZABETH
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1366869208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 WALLACE AVE
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
LEITCHFIELD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42754-1479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-259-5641
Provider Business Mailing Address Fax Number:
270-259-5309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 WALLACE AVE
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
LEITCHFIELD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42754-1479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-259-5641
Provider Business Practice Location Address Fax Number:
270-259-5309
Provider Enumeration Date:
03/27/2014

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 50135 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100360200 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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