Provider Demographics
NPI:1114904729
Name:STEVENS, TYLER K (MD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:K
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 1:9500 EUCLID AVE # A31
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-445-1996
Mailing Address - Fax:216-444-6284
Practice Address - Street 1:4095 MEADOWBROOK BLVD
Practice Address - Street 2:
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-3854
Practice Address - Country:US
Practice Address - Phone:216-371-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-081031207R00000X
OH81031207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2355768Medicaid
OH000000332717OtherANTHEM
OH2355768Medicaid
OHI24187Medicare UPIN