Provider Demographics
NPI:1467568741
Name:MERRITT-JENNEY, STACEY EILEEN (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:EILEEN
Last Name:MERRITT-JENNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 DUTCHMANS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3271
Mailing Address - Country:US
Mailing Address - Phone:502-456-6200
Mailing Address - Fax:502-456-6655
Practice Address - Street 1:6200 DUTCHMANS LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3271
Practice Address - Country:US
Practice Address - Phone:502-456-6200
Practice Address - Fax:502-456-6655
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041029A207P00000X, 207PH0002X
KY28829207P00000X, 207PH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000185657OtherANTHEM
KY2437324000OtherPASSPORT ADVANTAGE
KY64018880Medicaid
KY1124516OtherPASSPORT
IN200009620Medicaid
KY930106019Medicare PIN
KY64018880Medicaid
KY1124516OtherPASSPORT