Provider Demographics
NPI:1558318220
Name:ALTOBELLIS, STEPHANIE S (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:S
Last Name:ALTOBELLIS
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 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-897-0272
Mailing Address - Fax:502-897-0275
Practice Address - Street 1:6420 DUTCHMANS PKWY STE 165
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3353
Practice Address - Country:US
Practice Address - Phone:502-897-0272
Practice Address - Fax:502-897-0275
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27437207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00546116Medicare Oscar/Certification
KYP00301257Medicare PIN
KYF23740Medicare UPIN