Basic Information
| Provider Information | |||||||||
| NPI: | 1629076633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGGEMEYER | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012663 | ||||||||
| FaxNumber: | 8598177848 | ||||||||
| Practice Location | |||||||||
| Address1: | 4355 FERGUSON DR | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452455136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132212663 | ||||||||
| FaxNumber: | 8598177848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT08488 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00306306 | 01 | OH | MEDICARE RAILROAD | OTHER | 000000322387 | 01 | OH | ANTHEM | OTHER | 9342356 | 01 | OH | PHCS | OTHER | 000000322287 | 01 | OH | ANTHEM | OTHER | 2507040 | 05 | OH | MEDICAID |