Provider Demographics
NPI:1073569018
Name:FUSSELL, STEPHANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1234
Mailing Address - Fax:228-575-1240
Practice Address - Street 1:1340 BROAD AVE STE 330
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2464
Practice Address - Country:US
Practice Address - Phone:228-575-1234
Practice Address - Fax:228-867-4828
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16995207RH0002X, 207RX0202X
AL00025974207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00236384Medicaid
ALP00122585OtherMEDICARE RAILROAD
AL529501680Medicaid
AL51523039OtherBLUE CROSS ID#
AL51523039OtherBLUE CROSS ID#
AL529501680Medicaid
ALP00122585OtherMEDICARE RAILROAD