Provider Demographics
NPI:1801817564
Name:CHURCH, STEPHEN H (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
Last Name:CHURCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 WESTPORT RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2739
Mailing Address - Country:US
Mailing Address - Phone:502-896-8868
Mailing Address - Fax:502-895-6278
Practice Address - Street 1:4171 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2739
Practice Address - Country:US
Practice Address - Phone:502-896-8868
Practice Address - Fax:502-895-6278
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19565208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64195654Medicaid
KY64195654Medicaid
KYD95927Medicare UPIN