1114249455 NPI number — REGINA A STEVENS

Table of content: REGINA A STEVENS (NPI 1114249455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114249455 NPI number — REGINA A STEVENS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS
Provider First Name:
REGINA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1114249455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 BOURNE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42501-1916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-678-4761
Provider Business Mailing Address Fax Number:
606-676-9671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 ADAMS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-678-4761
Provider Business Practice Location Address Fax Number:
606-676-9671
Provider Enumeration Date:
02/26/2010

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: 133V00000X , with the licence number:  1726 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20044012 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20100012 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20027017 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20116018 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20029013 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20109013 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20023016 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20101014 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20901211 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20001012 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20074019 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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