Provider Demographics
NPI:1982684726
Name:RUSSELL, STEPHANIE M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:RUSSELL
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 1:10639 MEETING STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40059-7544
Mailing Address - Country:US
Mailing Address - Phone:502-425-7827
Mailing Address - Fax:502-412-3979
Practice Address - Street 1:10639 MEETING STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40059-7544
Practice Address - Country:US
Practice Address - Phone:502-425-7827
Practice Address - Fax:502-412-3979
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33992208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64012016Medicaid
KY1840701Medicare ID - Type Unspecified
H17795Medicare UPIN
KY0773342Medicare PIN