Provider Demographics
NPI:1689642340
Name:STEVENSON, RODRICK ALBERT (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:RODRICK
Middle Name:ALBERT
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:PO BOX 3127
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:699 RURAL AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3246
Practice Address - Country:US
Practice Address - Phone:570-321-3180
Practice Address - Fax:570-321-3181
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD047042L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5166004OtherAETNA
PA0017727370011Medicaid
PA698487OtherHIGHMARK BLUE SHIELD
PA1276362OtherUNITEDHEALTHCARE
PA819135OtherFIRST PRIORITY HEALTH
PAF91721OtherHEALTHAMERICA
PA0017727370011Medicaid
PA032117Medicare PIN
PAF91721OtherHEALTHAMERICA