MEDICARE: STACIE GROSSFELD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	33575	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1299470001	OTHER	KY	PTAN

General Provider Information

NPI Number	:	1710980842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE GROSSFELD M.D.

Provider Business Mailing Address
First Line	:	4001 KRESGE WAY
Second Line	:	STE 330
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4640
Country	:	US
Telephone Number	:	502-212-2663
Fax Number	:	502-212-2004

Provider Business Practice Location Address
First Line	:	4001 KRESGE WAY
Second Line	:	STE 330
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4640
Country	:	US
Telephone Number	:	502-212-2663
Fax Number	:	502-212-2004

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	09/14/2011

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