Provider Demographics
NPI:1255464236
Name:STAVENS, GERASIMOS S (MD)
Entity Type:Individual
Prefix:
First Name:GERASIMOS
Middle Name:S
Last Name:STAVENS
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 1:100 MALLARD CREEK RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4194
Mailing Address - Country:US
Mailing Address - Phone:502-589-7907
Mailing Address - Fax:502-589-1319
Practice Address - Street 1:100 MALLARD CREEK RD
Practice Address - Street 2:SUITE 150
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4194
Practice Address - Country:US
Practice Address - Phone:502-589-7907
Practice Address - Fax:502-589-1319
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38382207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY060052921OtherRAILROAD MEDICARE
OK200198560AMedicaid
IN201275370Medicaid
000000909758OtherANTHEM
KY7100326390Medicaid
INP01433982OtherRAILROAD MEDICARE
KY060052921OtherRAILROAD MEDICARE
IN201275370Medicaid
IN084820001Medicare PIN