Healthcare Provider Details

I. General information

NPI: 1164508198
Provider Name (Legal Business Name): STEPHANIE M. RUSSELL MD PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10639 MEETING STREET SUITE 101
PROSPECT KY
40059-7544
US

IV. Provider business mailing address

10639 MEETING STREET SUITE 101
PROSPECT KY
40059-7544
US

V. Phone/Fax

Practice location:
  • Phone: 502-425-7827
  • Fax: 502-412-3979
Mailing address:
  • Phone: 502-425-7827
  • Fax: 502-412-3979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateKY

VIII. Authorized Official

Name: STEPHANIE M. RUSSELL
Title or Position: OWNER
Credential: MD
Phone: 502-425-7827