Healthcare Provider Details

I. General information

NPI: 1770089450
Provider Name (Legal Business Name): STEPHANIE ANN BODEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 CENTRAL AVE
LOUISVILLE KY
40208-1449
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4521
  • Fax:
Mailing address:
  • Phone: 502-588-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number59249
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.163992
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: