Provider Demographics
NPI:1457375289
Name:STEPHENS, SCOTT MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MATTHEW
Last Name:STEPHENS
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 1:110 HARDIN LN
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3818
Mailing Address - Country:US
Mailing Address - Phone:606-679-9268
Mailing Address - Fax:606-677-1020
Practice Address - Street 1:110 HARDIN LN
Practice Address - Street 2:SUITE 10
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3818
Practice Address - Country:US
Practice Address - Phone:606-679-9268
Practice Address - Fax:606-677-1020
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29795207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
61,1355693OtherTAX ID
KY64297955Medicaid
KY29795OtherKENTUCKY LICENSE
KY00346006Medicare PIN
KYG23557Medicare UPIN
KY64297955Medicaid
KY29795OtherKENTUCKY LICENSE