Provider Demographics
NPI:1437654050
Name:PREDEBON, STEPHEN RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RAYMOND
Last Name:PREDEBON
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 1:107 ROYAL BIRKDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-8493
Mailing Address - Country:US
Mailing Address - Phone:330-482-9350
Mailing Address - Fax:330-482-2336
Practice Address - Street 1:107 ROYAL BIRKDALE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-8493
Practice Address - Country:US
Practice Address - Phone:330-482-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.141275207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0451769Medicaid