Provider Demographics
NPI:1598746018
Name:STEPHENSON, KEITH R (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:STEPHENSON
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 1:301 CRAIG DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-1830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 LAMB CIR
Practice Address - Street 2:SUITE 300
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6344
Practice Address - Country:US
Practice Address - Phone:540-639-5900
Practice Address - Fax:540-639-0976
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-233788208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007313420Medicaid
VA010269024Medicaid
VA007313411Medicaid
VA007313560Medicaid
VA000080C08Medicare PIN
VAF41772Medicare UPIN
VA010269024Medicaid
VA007313420Medicaid
VA018104C18Medicare PIN