Provider Demographics
NPI:1386018984
Name:STEPHEN LACKY CHASTAIN
Entity Type:Organization
Organization Name:STEPHEN LACKY CHASTAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-581-3991
Mailing Address - Street 1:9611 N US HIGHWAY 1
Mailing Address - Street 2:#166
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-6363
Mailing Address - Country:US
Mailing Address - Phone:772-581-3990
Mailing Address - Fax:772-581-3991
Practice Address - Street 1:5850 SE COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6420
Practice Address - Country:US
Practice Address - Phone:772-324-3901
Practice Address - Fax:772-324-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114042207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009031100Medicaid
FL61656OtherBCBS
FLME114042OtherLICENSE
FLME114042OtherLICENSE