Provider Demographics
NPI:1346621505
Name:LORTS, STEPHANIE N (MD)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:N
Last Name:LORTS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:N
Other - Last Name:CZESCHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4804 SOUTH STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034
Mailing Address - Country:US
Mailing Address - Phone:618-288-9305
Mailing Address - Fax:618-288-9308
Practice Address - Street 1:4804 SOUTH STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-288-9305
Practice Address - Fax:618-288-9308
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015017245208000000X
IL036146838208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics