Provider Demographics
NPI:1821043092
Name:STEPHENSON, JAMES EDMOND (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:EDMOND
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:890 W FARIS RD
Practice Address - Street 2:SUITE 320
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4253
Practice Address - Country:US
Practice Address - Phone:864-455-1200
Practice Address - Fax:864-455-1209
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10394208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00817204OtherRR MEDICARE
SC103943Medicaid
SCD056727951Medicare PIN
SC103943Medicaid
SCD056723640Medicare PIN