Provider Demographics
NPI:1093026627
Name:PACIFICO, STEPHEN E (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:PACIFICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:250 BMH PHYSICIANS OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5904
Practice Address - Country:US
Practice Address - Phone:865-980-5244
Practice Address - Fax:865-980-5245
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD53188208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ015220Medicaid
TN103I025862Medicare PIN