Provider Demographics
NPI:1043246838
Name:STEVENSON, ELLEN B (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2801 N GANTENBEIN AVE
Mailing Address - Street 2:DEPARTMENT OF PEDIATRICS, LEGACY EMANUEL HOSPITAL
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-413-2402
Mailing Address - Fax:503-413-2566
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS, LEGACY EMANUEL HOSPITAL
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-2402
Practice Address - Fax:503-413-2566
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD27853208M00000X
GA046652208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270994Medicaid
GA000917936KMedicaid
WA8155160Medicaid