Provider Demographics
NPI:1649260530
Name:PAYNE, STEPHEN R (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:PAYNE
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 166
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-0166
Mailing Address - Country:US
Mailing Address - Phone:802-524-2168
Mailing Address - Fax:802-524-0411
Practice Address - Street 1:148 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1729
Practice Address - Country:US
Practice Address - Phone:802-524-2168
Practice Address - Fax:802-524-0411
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007703174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT28637OtherBLUE CROSS BLUE SHIELD
VT0009263Medicaid
VT02V011OtherMVP HEALTH CARE
VT4671301OtherFAHC PREFERRED
VT28637OtherBLUE CROSS BLUE SHIELD
VT0009263Medicaid