Provider Demographics
NPI:1770629099
Name:ROUSSELL, STACEY STOKES (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:STOKES
Last Name:ROUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5337
Practice Address - Street 1:4010 DUPONT CIR
Practice Address - Street 2:SUITE 283
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4812
Practice Address - Country:US
Practice Address - Phone:502-897-1727
Practice Address - Fax:502-895-0827
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY350052080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000200556OtherANTHEM
KY611356201OtherTAX ID
KY64035678Medicaid
KY50035679OtherPASSPORT - KCMA
KY129357OtherSIHO - KCMA
KY000000739400OtherANTHEM - KCMA
KY000000200556OtherPASSPORT HEALTH PLAN
KY64035678Medicaid