Provider Demographics
NPI:1700249026
Name:STEVENS, MICHAEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:STEVENS
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 1:1 ILLINI DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-2576
Mailing Address - Country:US
Mailing Address - Phone:309-655-4746
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-5243
Practice Address - Country:US
Practice Address - Phone:093-655-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125068180207R00000X
MI43015017402080P0203X
IL036.1630902080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine