Healthcare Provider Details

I. General information

NPI: 1962060814
Provider Name (Legal Business Name): STEPHEN MICHAEL NELLIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 E PARRISH AVE
OWENSBORO KY
42303-1448
US

IV. Provider business mailing address

2060 E PARRISH AVE
OWENSBORO KY
42303-1448
US

V. Phone/Fax

Practice location:
  • Phone: 270-684-5034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0000004954
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4954
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4954
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4954
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4954
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4954
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4954
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: