Basic Information
Provider Information | |||||||||
NPI: | 1366617078 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEPHENSON | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | STUART | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 776351 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022725063 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9880 ANGIES WAY | ||||||||
Address2: | 250 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402412851 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5023946341 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2008 | ||||||||
LastUpdateDate: | 10/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 45055 | KY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QS0010X | 45055 | KY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 767416 | 01 | KY | ANTHEM- NORTON MEDICAL ASSOCIATES | OTHER | K043290 | 01 | KY | MEDICARE- NMA OBC | OTHER | 201221810 | 05 | IN |   | MEDICAID | 50039136 | 01 | KY | PASSPORT HEALTH- NMA OBC | OTHER | 6222460 | 01 | KY | CIGNA- NORTON MEDICAL ASSOCIATES | OTHER | 7100203090 | 05 | KY |   | MEDICAID |