Provider Demographics
NPI:1164750949
Name:TOMMY S. STEVENS M.D., P.C.
Entity Type:Organization
Organization Name:TOMMY S. STEVENS M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EDELEN-STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-742-2544
Mailing Address - Street 1:2298 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1166
Mailing Address - Country:US
Mailing Address - Phone:810-742-2544
Mailing Address - Fax:810-742-2566
Practice Address - Street 1:2298 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1166
Practice Address - Country:US
Practice Address - Phone:810-742-2544
Practice Address - Fax:810-742-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITS039213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4328356Medicaid
MION33340Medicare PIN
MIA78452Medicare UPIN