Provider Demographics
NPI:1619905809
Name:STEPHENSON, KATHRYN ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANNE
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHRYN
Other - Middle Name:A
Other - Last Name:HICKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 310
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6883
Practice Address - Country:US
Practice Address - Phone:803-434-2300
Practice Address - Fax:803-434-8686
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17543208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC175438Medicaid
G41903Medicare UPIN
SCG419032389Medicare PIN