Provider Demographics
NPI:1619944477
Name:STEVENS, PHILLIP R (MD)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:R
Last Name:STEVENS
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:#3 STONECREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:304-522-6388
Mailing Address - Fax:304-522-8040
Practice Address - Street 1:#3 STONECREST DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-522-6388
Practice Address - Fax:304-522-8040
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15360207Y00000X
OH35078614S207Y00000X
KY30789207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0101200000Medicaid
KY64697220Medicaid
OH0698759Medicaid
OHDE0250Medicare PIN
OH0698759Medicaid
WVCI167Medicare PIN
KY64697220Medicaid
WV0101200000Medicaid
WV9299541Medicare PIN
OH9299542Medicare PIN