Provider Demographics
NPI:1053415570
Name:COLE, STEPHEN ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANDREW
Last Name:COLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:107 PRAIRIE DR
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184-9794
Mailing Address - Country:US
Mailing Address - Phone:865-789-1747
Mailing Address - Fax:
Practice Address - Street 1:525 KENOSHA ST
Practice Address - Street 2:SUITE A
Practice Address - City:WALWORTH
Practice Address - State:WI
Practice Address - Zip Code:53184-9512
Practice Address - Country:US
Practice Address - Phone:262-275-2101
Practice Address - Fax:262-275-0752
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61002-20207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734041Medicare PIN