Provider Demographics
NPI:1306185798
Name:STALLWORTH INTERNAL MEDICINE AND PEDIATRICS
Entity type:Organization
Organization Name:STALLWORTH INTERNAL MEDICINE AND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:LOVIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-242-2077
Mailing Address - Street 1:2010 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-2829
Mailing Address - Country:US
Mailing Address - Phone:606-242-2077
Mailing Address - Fax:606-242-2027
Practice Address - Street 1:2010 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2829
Practice Address - Country:US
Practice Address - Phone:606-242-2077
Practice Address - Fax:606-242-2027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40788208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H20832Medicare UPIN