Provider Demographics
NPI:1073596730
Name:STEVENS, ROM A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROM
Middle Name:A
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-489-9000
Mailing Address - Fax:
Practice Address - Street 1:5900 S LAKE DR
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-3171
Practice Address - Country:US
Practice Address - Phone:414-489-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-26
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25448-020208VP0014X
WI25448207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31779900Medicaid
WI31779900Medicaid
C22265Medicare UPIN
WI0017-60005Medicare ID - Type UnspecifiedPROVIDER NUMBER
ILL94320-203133Medicare ID - Type UnspecifiedPROVIDER NUMBER