Provider Demographics
NPI:1164508198
Name:STEPHANIE M. RUSSELL MD PSC
Entity Type:Organization
Organization Name:STEPHANIE M. RUSSELL MD PSC
Other - Org Name:KIDZLIFE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-425-7827
Mailing Address - Street 1:10639 MEETING STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-7544
Mailing Address - Country:US
Mailing Address - Phone:502-425-7827
Mailing Address - Fax:502-412-3979
Practice Address - Street 1:10639 MEETING STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-7544
Practice Address - Country:US
Practice Address - Phone:502-425-7827
Practice Address - Fax:502-412-3979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY208000000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200314560AMedicaid
KY1840701Medicare PIN