Provider Demographics
NPI:1730205063
Name:DREISBACH, STEPHEN KYLE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KYLE
Last Name:DREISBACH
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:6400 DUTCHMANS PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3340
Practice Address - Country:US
Practice Address - Phone:502-894-2444
Practice Address - Fax:502-894-2445
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000712995OtherANTHEM - NCMA
KY125976OtherSIHO - NCMA
KY3723485000OtherPASSPORT ADVANTAGE
KY7100085660Medicaid
KY50033196OtherPASSPORT/PASSPORT ADV - NCMA
KY5360772OtherCIGNA - NCMA
KY000000623621OtherANTHEM
KY000057120FOtherHUMANA - NCMA
KY50024602OtherPASSPORT
KYP00946146Medicare PIN
KY00162077Medicare PIN
KY000000623621OtherANTHEM