Provider Demographics
NPI:1710943683
Name:PETER L. STEVENSON, MD, PC
Entity Type:Organization
Organization Name:PETER L. STEVENSON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-278-3900
Mailing Address - Street 1:2100 MONROE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-278-3900
Mailing Address - Fax:313-278-4821
Practice Address - Street 1:2100 MONROE STREET
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-278-3900
Practice Address - Fax:313-278-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPS050235174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0824969Medicare ID - Type Unspecified