Healthcare Provider Details

I. General information

NPI: 1770542441
Provider Name (Legal Business Name): KENNETH SAMUEL STONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 N 16TH ST SUITE A
LAFAYETTE IN
47904-2119
US

IV. Provider business mailing address

PO BOX 5545
LAFAYETTE IN
47903-5545
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-448-8054
Mailing address:
  • Phone: 765-448-8000
  • Fax: 765-448-8085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number01036689A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: