Provider Demographics
NPI:1063545275
Name:STIDAM, JEFFREY M (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:STIDAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LIBERTY ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1428
Mailing Address - Country:US
Mailing Address - Phone:502-585-4321
Mailing Address - Fax:502-566-6338
Practice Address - Street 1:225 ABRAHAM FLEXNER WAY
Practice Address - Street 2:SUITE 305
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1882
Practice Address - Country:US
Practice Address - Phone:502-585-4321
Practice Address - Fax:502-566-6338
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063360A207RC0000X, 207RC0001X
KY39017207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200856500Medicaid
KY7100069260Medicaid
IN228550PMedicare PIN
KYP00710176Medicare PIN
KY7100069260Medicaid
INP400032915Medicare PIN