MEDICARE: MR. STEPHEN KIRK DOUGLAS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	71001649A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000321795	OTHER	IN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1497733109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN KIRK DOUGLAS NP

Provider Business Mailing Address
First Line	:	1481 W 10TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-2803
Country	:	US
Telephone Number	:	317-988-2972
Fax Number	:

Provider Business Practice Location Address
First Line	:	2675 FOXPOINTE DRIVE
Second Line	:	SUITE B
City	:	COLUMBUS
State	:	IN
Zip	:	47203
Country	:	US
Telephone Number	:	812-375-0000
Fax Number	:	812-375-0711

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	01/28/2016

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