Provider Demographics
NPI:1164733507
Name:PANNELL, STEPHANIE MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARY
Last Name:PANNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE
Mailing Address - Street 2:FL 3
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-7100
Mailing Address - Fax:419-383-2000
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3759
Practice Address - Fax:419-383-3105
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.128287208C00000X
OH35128287208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0166466Medicaid
OH0166466Medicaid