Provider Demographics
NPI:1477513828
Name:OLIVERIUS, STANLEY JEROME (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:JEROME
Last Name:OLIVERIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S
Other - Middle Name:JEROME
Other - Last Name:OLIVERIUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1850 N CENTRAL AVE
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4527
Mailing Address - Country:US
Mailing Address - Phone:602-744-4765
Mailing Address - Fax:602-744-4799
Practice Address - Street 1:1850 N CENTRAL AVE
Practice Address - Street 2:SUITE 1600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4527
Practice Address - Country:US
Practice Address - Phone:602-744-4765
Practice Address - Fax:602-744-4799
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16120207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ257297Medicaid
050074479OtherMEDICARE RAILROAD
050074479OtherMEDICARE RAILROAD
AZZ21353Medicare PIN