Provider Demographics
NPI:1417932732
Name:IRVIN, STEPHEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:B
Last Name:IRVIN
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 1:240 BROOKFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-3287
Mailing Address - Country:US
Mailing Address - Phone:276-236-3145
Mailing Address - Fax:
Practice Address - Street 1:199 HOSPITAL DR
Practice Address - Street 2:SUITE 7
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2454
Practice Address - Country:US
Practice Address - Phone:276-236-5181
Practice Address - Fax:276-236-3297
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2008-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-019282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005623324Medicaid
VA010027080Medicaid
VA005634504Medicaid
VA005623324Medicaid
80006727Medicare PIN
B08813Medicare UPIN
003356C63Medicare PIN
VA017829C18Medicare PIN