Provider Demographics
NPI:1962494526
Name:STEPHENS, GREGORY E (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:E
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 KING RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7952
Mailing Address - Country:US
Mailing Address - Phone:734-479-7310
Mailing Address - Fax:
Practice Address - Street 1:14600 KING RD
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-7952
Practice Address - Country:US
Practice Address - Phone:734-479-7310
Practice Address - Fax:734-479-7307
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010374207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3086232Medicaid
MI383461449OtherFEDERAL TAX ID
MI0158223820OtherBLUE CROSS MICHIGAN
MIP85024OtherBLUE CARE NETWORK
MIC5211OtherMCARE
MI383461449OtherFEDERAL TAX ID
MI3086232Medicaid
MI5822382Medicare ID - Type UnspecifiedMEDICARE