Healthcare Provider Details

I. General information

NPI: 1811101108
Provider Name (Legal Business Name): STEPHEN MICHAEL CLANCY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 LEESTOWN RD
LEXINGTON KY
40511-8702
US

IV. Provider business mailing address

1805 HAVERWOOD PARK
LEXINGTON KY
40514-1831
US

V. Phone/Fax

Practice location:
  • Phone: 859-255-6812
  • Fax: 859-253-8828
Mailing address:
  • Phone: 859-523-3943
  • Fax: 859-201-1234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number36160
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: