Provider Demographics
NPI:1306843446
Name:STEVENS, JEREMY SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SHANE
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1004 HEALTH CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9253
Practice Address - Country:US
Practice Address - Phone:217-238-3435
Practice Address - Fax:217-238-3492
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA231357207X00000X
IL036-111903207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery