1649251091 NPI number — MEKEIA H STEVENSON PT

Table of content: MEKEIA H STEVENSON PT (NPI 1649251091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649251091 NPI number — MEKEIA H STEVENSON PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENSON
Provider First Name:
MEKEIA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARRIS
Provider Other First Name:
MEKEIA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649251091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4123 ASHMORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27405-6301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-708-9266
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6320A W UNION HILLS DR
Provider Second Line Business Practice Location Address:
STE 265
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-1098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-374-2424
Provider Business Practice Location Address Fax Number:
623-374-2619
Provider Enumeration Date:
11/10/2005

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: 225100000X , with the licence number:  9619 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 9447 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2023 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Z155550 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 7211729 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00319082 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 079RX . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: E2225 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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