Provider Demographics
NPI:1114035896
Name:STEVENS, NATHAN A
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:A
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
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 247
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-0247
Mailing Address - Country:US
Mailing Address - Phone:618-395-2225
Mailing Address - Fax:
Practice Address - Street 1:600 WEST MAIN
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2623
Practice Address - Country:US
Practice Address - Phone:618-395-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008490111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08022501OtherBLUE CROSS BLUE SHIELD
IL038008490Medicaid
IL350044665OtherRAILROAD MEDICARE
IL508030Medicare ID - Type Unspecified
IL038008490Medicaid