Basic Information
| Provider Information | |||||||||
| NPI: | 1811937782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAYNE | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4631 RIDGE AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452091028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136311268 | ||||||||
| FaxNumber: | 5133664121 | ||||||||
| Practice Location | |||||||||
| Address1: | 4631 RIDGE AVENUE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136311268 | ||||||||
| FaxNumber: | 5133664121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35042483P | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64934094 | 05 | KY | MEDICAID | 0451541 | 05 | OH | MEDICAID |