Basic Information
| Provider Information | |||||||||
| NPI: | 1417971086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ARDOIN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | PAYNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 CHILDRENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147222000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 35075002 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 2080P0216X | 35075002 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | H138151-OSU | 01 | OH | CGS - MEDICARE | OTHER | H138151 | 01 | OH | CGS - MEDICARE | OTHER | 2246608 | 05 | OH | MEDICAID |