1093828295 NPI number — MICHAEL FRANCIS STEVENS PT CERT MDT

Table of content: MICHAEL FRANCIS STEVENS PT CERT MDT (NPI 1093828295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093828295 NPI number — MICHAEL FRANCIS STEVENS PT CERT MDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS
Provider First Name:
MICHAEL
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT CERT MDT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093828295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021A EMMORTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEL AIR
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21015-8962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-515-0006
Provider Business Practice Location Address Fax Number:
410-515-0027
Provider Enumeration Date:
08/15/2006

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:  17927 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1093828295 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3512475000 . This is a "IBC AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10764015 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 214882 . This is a "JOHNS HOPKINS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5070-0101 . This is a "GHMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 88760511 . This is a "BC MARYLAND" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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