Provider Demographics
NPI:1679558787
Name:HUBBARD, STEPHANIE HARRISON (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE HARRISON
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M D
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:RCS PROVIDER ENROLLMENT
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:765-254-4009
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-751-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060671207L00000X
IN01080270A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403262400Medicaid
MD858MK770Medicare ID - Type Unspecified