1184973109 NPI number — JOHNNA HICKS STEVENS M.D.

Table of content: JOHNNA HICKS STEVENS M.D. (NPI 1184973109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184973109 NPI number — JOHNNA HICKS STEVENS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS
Provider First Name:
JOHNNA
Provider Middle Name:
HICKS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HICKS
Provider Other First Name:
JOHNNA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184973109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 RIBAUT RD
Provider Second Line Business Mailing Address:
BMAC CREDENTIALING
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29902-5441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-522-7843
Provider Business Mailing Address Fax Number:
843-522-5678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BEAUFORT MEMORIAL BLUFFTON PRIMARY CARE
Provider Second Line Business Practice Location Address:
11 ARLEY WAY, STE 201
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910-4883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-706-8690
Provider Business Practice Location Address Fax Number:
844-295-9802
Provider Enumeration Date:
09/05/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  78307 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 81571 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 81571 . This is a "STATE LICENSE BOARD" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 815719 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".