Provider Demographics
NPI:1659320778
Name:STEVENS, THOMAS HALE (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HALE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-1167
Mailing Address - Country:US
Mailing Address - Phone:260-665-9479
Mailing Address - Fax:260-665-9470
Practice Address - Street 1:903 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-1167
Practice Address - Country:US
Practice Address - Phone:260-665-9479
Practice Address - Fax:260-665-9470
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000795A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1838561Medicaid
IN100225560Medicaid
IN000000079425OtherANTHEM BCBS
IN000000079425OtherANTHEM BCBS
IN770740Medicare ID - Type Unspecified