Provider Demographics
NPI:1629267315
Name:STEPHANIE N. SOUTHARD, PSC
Entity Type:Organization
Organization Name:STEPHANIE N. SOUTHARD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:606-340-8825
Mailing Address - Street 1:1215 N MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-2900
Mailing Address - Country:US
Mailing Address - Phone:606-340-8825
Mailing Address - Fax:606-340-0097
Practice Address - Street 1:1215 N MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2900
Practice Address - Country:US
Practice Address - Phone:606-340-8825
Practice Address - Fax:606-340-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02809261QP2300X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64061807Medicaid
KY64061807Medicaid