Provider Demographics
NPI:1093828295
Name:STEVENS, MICHAEL FRANCIS (PT CERT MDT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FRANCIS
Last Name:STEVENS
Suffix:
Gender:M
Credentials:PT CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021A EMMORTON RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-8962
Practice Address - Country:US
Practice Address - Phone:410-515-0006
Practice Address - Fax:410-515-0027
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1093828295OtherTRICARE
3512475000OtherIBC AMERIHEALTH
10764015OtherCAQH
214882OtherJOHNS HOPKINS
MD5070-0101OtherGHMSI
MD88760511OtherBC MARYLAND
136801ZBL8Medicare PIN
1093828295OtherTRICARE