Provider Demographics
NPI:1851540686
Name:TAYLOR, STEPHANIE PARKS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:PARKS
Last Name:TAYLOR
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01643207RH0002X, 207R00000X
MI4301508428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2519Medicaid
FL146R0OtherBLUE CROSS BLUE SHIELD
FL001577200Medicaid
NC1851540686Medicaid
SCNC2519Medicaid
FL001577200Medicaid
FLCR997ZMedicare PIN