Provider Demographics
NPI:1477739829
Name:MICHELLE H STEVENS MD PA
Entity Type:Organization
Organization Name:MICHELLE H STEVENS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:H
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-902-1282
Mailing Address - Street 1:4100 S FERDON BLVD
Mailing Address - Street 2:STE C5
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5252
Mailing Address - Country:US
Mailing Address - Phone:850-902-1282
Mailing Address - Fax:850-682-6937
Practice Address - Street 1:4100 S FERDON BLVD
Practice Address - Street 2:STE C5
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5252
Practice Address - Country:US
Practice Address - Phone:850-902-1282
Practice Address - Fax:850-682-6937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03170OtherBCBS
FL03170OtherBCBS
FLH08900Medicare UPIN