Provider Demographics
NPI:1750543591
Name:STIDHAM, LEANN MARIE (MD)
Entity type:Individual
Prefix:
First Name:LEANN
Middle Name:MARIE
Last Name:STIDHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEANN
Other - Middle Name:MARIE
Other - Last Name:GERKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1526
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-1526
Mailing Address - Country:US
Mailing Address - Phone:866-479-2711
Mailing Address - Fax:
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-522-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010660732085R0202X
IN11013417A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200989190Medicaid
IN000000712370OtherANTHEM
INM400020939Medicare PIN