Provider Demographics
NPI:1821042946
Name:STEVENSON, KEVIN LEE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:460 MALL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4801
Mailing Address - Country:US
Mailing Address - Phone:912-629-3527
Mailing Address - Fax:912-644-3369
Practice Address - Street 1:121 N CREST BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1845
Practice Address - Country:US
Practice Address - Phone:478-841-9333
Practice Address - Fax:478-272-3139
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA052640207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN983195000Medicaid
GA713638334EMedicaid
MN14BDHHSMedicare PIN
H17837Medicare UPIN