Basic Information
| Provider Information | |||||||||
| NPI: | 1922092931 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOUDER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | STANLEY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461400129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174686270 | ||||||||
| FaxNumber: | 3174686268 | ||||||||
| Practice Location | |||||||||
| Address1: | 8535 NORTH CLEARVIEW DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MCCORDSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460556055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173356960 | ||||||||
| FaxNumber: | 3173355031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
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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 | 207Q00000X | 01027577A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4072302 | 01 | IN | AETNA PIN # | OTHER | 200311740J,G | 01 | IN | MEDICAID GROUP#/LOCATION | OTHER | 100350300 | 05 | IN | MEDICAID | 000000396462 | 01 | IN | ANTHEM PIN # | OTHER |