Basic Information
| Provider Information | |||||||||
| NPI: | 1891778866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAMBOUGH | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4685 FOREST AVE | ||||||||
| Address2: | STE C | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452123359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138534749 | ||||||||
| FaxNumber: | 5138534740 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 SMITH RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NORWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132214848 | ||||||||
| FaxNumber: | 5138727825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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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 | 207X00000X | 35053396 | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 35053396 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | 35053396 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
| ID | Type | State | Issuer | Description | 0632202 | 05 | OH | MEDICAID |