Provider Demographics
NPI:1942408216
Name:STEPHENS CLINIC LLC
Entity Type:Organization
Organization Name:STEPHENS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-863-7021
Mailing Address - Street 1:1109 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 8A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6633
Mailing Address - Country:US
Mailing Address - Phone:706-863-7021
Mailing Address - Fax:706-651-6322
Practice Address - Street 1:1109 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 8A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6633
Practice Address - Country:US
Practice Address - Phone:706-863-7021
Practice Address - Fax:706-651-6322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040246207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD17802Medicare UPIN
GAI25888Medicare UPIN