Basic Information
| Provider Information | |||||||||
| NPI: | 1770520975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BISHOP YEATMAN | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BISHOP | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597814111 | ||||||||
| FaxNumber: | 8594415214 | ||||||||
| Practice Location | |||||||||
| Address1: | 2626 ALEXANDRIA PIKE | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND HEIGHTS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410761530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8597814111 | ||||||||
| FaxNumber: | 8594415214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39539 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00839854 | 01 | KY | RAILROAD MEDICARE | OTHER | P00243169 | 01 | KY | RAILROAD MEDICARE | OTHER | 2599997 | 05 | OH | MEDICAID | 64109945 | 05 | KY | MEDICAID |