Provider Demographics
NPI:1972571768
Name:SUTHERLAND, STEPHEN RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RAYMOND
Last Name:SUTHERLAND
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:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43301-0446
Mailing Address - Country:US
Mailing Address - Phone:740-341-5869
Mailing Address - Fax:
Practice Address - Street 1:165 W. CENTER ST.
Practice Address - Street 2:#401
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-3741
Practice Address - Country:US
Practice Address - Phone:740-382-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0533972084N0400X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0625658Medicaid
A16616Medicare UPIN
OH0588975Medicare PIN