Provider Demographics
NPI:1104890367
Name:DETTERLINE, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DETTERLINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E UNIVERSITY PKWY
Mailing Address - Street 2:33RD ST. PROFESSIONAL BLDG, STE 405
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2829
Mailing Address - Country:US
Mailing Address - Phone:410-554-2284
Mailing Address - Fax:410-554-2184
Practice Address - Street 1:201 E UNIVERSITY PKWY
Practice Address - Street 2:33RD ST. PROFESSIONAL BLDG, STE 405
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2829
Practice Address - Country:US
Practice Address - Phone:410-554-2284
Practice Address - Fax:410-554-2184
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36113740207R00000X
IL036113740208M00000X
OH35089436207R00000X, 208M00000X
MDD67439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100007510Medicaid
OH2745748Medicaid
IL36113740Medicaid
IN200867020Medicaid
ILK19284Medicare PIN
IN200867020Medicaid
KY7100007510Medicaid
I35416Medicare UPIN