Provider Demographics
NPI:1437363736
Name:STEPHENSON, GREGORY BROMMETT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:BROMMETT
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:6852 S OGLESBY AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-1324
Mailing Address - Country:US
Mailing Address - Phone:773-363-6985
Mailing Address - Fax:773-363-6985
Practice Address - Street 1:4320 FIR ST
Practice Address - Street 2:SUITE 210
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3052
Practice Address - Country:US
Practice Address - Phone:219-836-5464
Practice Address - Fax:219-228-4777
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-000611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200153400OtherINDIANA WELFARE
IN200153400OtherINDIANA WELFARE
ILK24398Medicare ID - Type UnspecifiedINDIVIDUAL
IN234790CMedicare PIN