Provider Demographics
NPI:1710980842
Name:GROSSFELD, STACIE (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:GROSSFELD
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 1:4001 KRESGE WAY
Mailing Address - Street 2:STE 330
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4640
Mailing Address - Country:US
Mailing Address - Phone:502-212-2663
Mailing Address - Fax:502-212-2004
Practice Address - Street 1:4001 KRESGE WAY
Practice Address - Street 2:STE 330
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-212-2663
Practice Address - Fax:502-212-2004
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1299470001OtherPTAN
KYG59497Medicare UPIN
KY1299470001OtherPTAN