Provider Demographics
NPI:1275689895
Name:PETERS, STEVANY L (MD)
Entity Type:Individual
Prefix:
First Name:STEVANY
Middle Name:L
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ELLIOTT DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8632
Mailing Address - Country:US
Mailing Address - Phone:734-434-6262
Mailing Address - Fax:734-712-2820
Practice Address - Street 1:5300 ELLIOTT DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8632
Practice Address - Country:US
Practice Address - Phone:734-434-6262
Practice Address - Fax:734-728-2820
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094749207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H14989OtherBCBS GROUP
MI9719366OtherAETNA
MI0810847OtherBCBS INDIVIDUAL
MI1275689895Medicaid
MIP00773688OtherMEDICARE RAILROAD PTAN
MI9719366OtherAETNA
MI0H14989OtherBCBS GROUP