Provider Demographics
NPI:1548544570
Name:J. CRAIG STEVENS MD PC
Entity type:Organization
Organization Name:J. CRAIG STEVENS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-613-1580
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:CLARK FORK
Mailing Address - State:ID
Mailing Address - Zip Code:83811-0353
Mailing Address - Country:US
Mailing Address - Phone:208-266-1677
Mailing Address - Fax:
Practice Address - Street 1:750 N SYRINGA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5275
Practice Address - Country:US
Practice Address - Phone:800-613-1580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID75072081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805192200Medicaid
1139519Medicare PIN