Provider Demographics
NPI:1669541066
Name:ETOCH, STEVEN WAYNE (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:WAYNE
Last Name:ETOCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3 AUDUBON PLAZA DR STE 560
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1376
Practice Address - Country:US
Practice Address - Phone:502-636-8004
Practice Address - Fax:502-636-8384
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28801208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000497079OtherANTHEM - CTS
2834557000OtherPAD - CTS 560
083219OtherSIHO - CTS
IN200182720Medicaid
KY64288012Medicaid
KYP00368248OtherRRMCR - CTS
50014460OtherPASSPORT - CTS 560
IN200182720Medicaid
KYF78929Medicare UPIN
KYP00368248OtherRRMCR - CTS