Provider Demographics
NPI:1588835433
Name:GREGORY E STEPHENS DO PC
Entity Type:Organization
Organization Name:GREGORY E STEPHENS DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:E
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-479-7310
Mailing Address - Street 1:14600 KING RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7952
Mailing Address - Country:US
Mailing Address - Phone:734-479-7310
Mailing Address - Fax:
Practice Address - Street 1:14600 KING RD
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7952
Practice Address - Country:US
Practice Address - Phone:734-479-7310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010374174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4384248Medicaid
MI0158223820OtherBLUE CROSS OF MICHIGAN
MI0158223820OtherBLUE CROSS OF MICHIGAN
MI0P57550Medicare PIN
MI=========OtherCOMMERICAL INSURANCE
MI4384248Medicaid