Basic Information
| Provider Information | |||||||||
| NPI: | 1770593626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STABEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 CHINOE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405021959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592778179 | ||||||||
| FaxNumber: | 8592779320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1780 NICHOLASVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592778179 | ||||||||
| FaxNumber: | 8592779320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34800 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64018203 | 05 | KY | MEDICAID |