1578604005 NPI number — DR. STEPHEN STIVERS DPM

Table of content: DR. STEPHEN STIVERS DPM (NPI 1578604005)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578604005 NPI number — DR. STEPHEN STIVERS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STIVERS
Provider First Name:
STEPHEN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1578604005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 KENTUCKY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42003-3202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-444-9011
Provider Business Mailing Address Fax Number:
270-444-9902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 KENTUCKY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42003-3202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-444-9011
Provider Business Practice Location Address Fax Number:
270-444-9902
Provider Enumeration Date:
02/09/2007

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: 213E00000X , with the licence number:  163 , 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: 62186125242003A001 . This is a "WPS TRICARE FOR LIFE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: KY0057841 . This is a "TRICARE NORTH PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 137000 . This is a "HEALTHLINK PROVIDER ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000204311 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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