Provider Demographics
NPI:1265405468
Name:RUSS-BARBER, STEPHANIE L (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:L
Last Name:RUSS-BARBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-500-2144
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:2587 WILLOW POINT WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-3162
Practice Address - Country:US
Practice Address - Phone:865-470-2560
Practice Address - Fax:865-691-5883
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051725208000000X
SCTL28480208000000X
TN48935208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085003062GMedicaid
TNQ000722Medicaid