Provider Demographics
NPI:1952833295
Name:STOVER, GARY JR
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:STOVER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1902
Mailing Address - Country:US
Mailing Address - Phone:317-338-6399
Mailing Address - Fax:
Practice Address - Street 1:800 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3778
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036156475208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program