Healthcare Provider Details

I. General information

NPI: 1255464236
Provider Name (Legal Business Name): GERASIMOS S STAVENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MALLARD CREEK RD SUITE 150
LOUISVILLE KY
40207-4194
US

IV. Provider business mailing address

100 MALLARD CREEK RD SUITE 150
LOUISVILLE KY
40207-4194
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-7907
  • Fax: 502-589-1319
Mailing address:
  • Phone: 502-589-7907
  • Fax: 502-589-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number38382
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number38382
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: