Basic Information
| Provider Information | |||||||||
| NPI: | 1710980842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROSSFELD | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4001 KRESGE WAY | ||||||||
| Address2: | STE 330 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022122663 | ||||||||
| FaxNumber: | 5022122004 | ||||||||
| Practice Location | |||||||||
| Address1: | 4001 KRESGE WAY | ||||||||
| Address2: | STE 330 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022122663 | ||||||||
| FaxNumber: | 5022122004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 33575 | KY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1299470001 | 01 | KY | PTAN | OTHER |