Provider Demographics
NPI:1982642146
Name:ADAMS, STENNETH G (MD)
Entity Type:Individual
Prefix:
First Name:STENNETH
Middle Name:G
Last Name:ADAMS
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:442 W HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1681
Practice Address - Country:US
Practice Address - Phone:419-636-4517
Practice Address - Fax:419-636-6438
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6972208600000X
OH35096886208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4319311OtherMEDICARE PTAN
OH3147071Medicaid