Provider Demographics
NPI:1477644722
Name:STEVENS, MARC J
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:J
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 ASHLEY PLACE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-9627
Mailing Address - Country:US
Mailing Address - Phone:803-234-4416
Mailing Address - Fax:
Practice Address - Street 1:4500 STUART ST
Practice Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-5700
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:803-751-2689
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00002104171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCVAD 000Medicare UPIN