1821013103 NPI number — DARRYL R. STEVENS DO

Table of content: DARRYL R. STEVENS DO (NPI 1821013103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821013103 NPI number — DARRYL R. STEVENS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS
Provider First Name:
DARRYL
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1821013103
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:
950 TAYLOR AVE STE 140
Provider Second Line Business Mailing Address:
LAKESHORE IMAGING CONSULTANTS, PLC
Provider Business Mailing Address City Name:
GRAND HAVEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49417-2281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-725-8119
Provider Business Mailing Address Fax Number:
616-846-1222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 E SHERMAN BLVD
Provider Second Line Business Practice Location Address:
MERCY GENERAL HEALTH PARTNERS - RADIOLOGY DEPT.
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49444-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-739-9341
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2006

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DS006137 . This is a "LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2747686 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".