Provider Demographics
NPI:1114951357
Name:BELGRAVE, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:BELGRAVE
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 1:602 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-3311
Mailing Address - Fax:
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360719622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2613OtherMEDICARE GROUP #
ILC48197Medicare UPIN
IL2613OtherMEDICARE GROUP #