Provider Demographics
NPI:1902883481
Name:HIMMELSTEIN, STEVAN I (MD)
Entity Type:Individual
Prefix:
First Name:STEVAN
Middle Name:I
Last Name:HIMMELSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1000 DEPT 960
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-435-8550
Mailing Address - Fax:901-516-0933
Practice Address - Street 1:1211 UNION AVE STE 965
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-435-8550
Practice Address - Fax:901-516-0933
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12664207RC0000X, 207RI0011X
TN20638207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117357001Medicaid
TN6092182OtherBCBS
MS00115478Medicaid
TN3807173Medicaid
AR85391OtherBCBS
TN3807173Medicaid
02100041701OtherQUALCHOICE
P00372265OtherRAIL ROAD MEDICARE
TN3807173Medicaid
TN000005008044OtherTLC