Healthcare Provider Details

I. General information

NPI: 1720148356
Provider Name (Legal Business Name): STEPHANIE SOUTHARD D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 HOSPITAL ST
MONTICELLO KY
42633-2430
US

IV. Provider business mailing address

166 HOSPITAL ST
MONTICELLO KY
42633-2430
US

V. Phone/Fax

Practice location:
  • Phone: 606-340-3251
  • Fax: 606-348-0618
Mailing address:
  • Phone: 606-340-3251
  • Fax: 606-348-0618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02809
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02809
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: