Provider Demographics
NPI:1841287075
Name:STOVER, MERVIN C III (MD)
Entity type:Individual
Prefix:
First Name:MERVIN
Middle Name:C
Last Name:STOVER
Suffix:III
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 1000
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0800
Mailing Address - Country:US
Mailing Address - Phone:219-864-2107
Mailing Address - Fax:219-864-2649
Practice Address - Street 1:513 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1647
Practice Address - Country:US
Practice Address - Phone:219-836-5738
Practice Address - Fax:219-836-5782
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024290A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL90000854OtherBCBSIL GROUP NUMBER
IN100141140Medicaid
IN100141140Medicaid
IN140220RRMedicare PIN