Basic Information
| Provider Information | |||||||||
| NPI: | 1932196615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 950202 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402950202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029696552 | ||||||||
| FaxNumber: | 5029693799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1207 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTOWN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427012709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707652107 | ||||||||
| FaxNumber: | 2707699642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2005 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 39461 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000379500 | 01 | ANTHEM - NCMA | OTHER | 2633023000 | 01 | PAD - NCMA | OTHER | 068871 | 01 | SIHO - NCMA | OTHER | 64105398 | 05 | KY | MEDICAID | 50007871 | 01 | PASSPORT - NCMA | OTHER |