Provider Demographics
NPI:1326528977
Name:STEVENSON ORTHOPEDIC SERVICES P.LLC
Entity Type:Organization
Organization Name:STEVENSON ORTHOPEDIC SERVICES P.LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-936-0303
Mailing Address - Street 1:3714 N 2455 E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5791
Mailing Address - Country:US
Mailing Address - Phone:208-936-0303
Mailing Address - Fax:
Practice Address - Street 1:4401 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-3507
Practice Address - Country:US
Practice Address - Phone:307-352-8930
Practice Address - Fax:307-352-8947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT764363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty