MEDICARE: MR. GENTRY W STEVENS A.S., B.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1710234968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GENTRY W STEVENS A.S., B.A.

Provider Business Mailing Address
First Line	:	1020 SYMMES RD
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-1844
Country	:	US
Telephone Number	:	513-645-4578
Fax Number	:	513-883-1546

Provider Business Practice Location Address
First Line	:	515 DAYTON ST
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45011-3455
Country	:	US
Telephone Number	:	513-868-7654
Fax Number	:	513-737-0026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2012
Last Update Date	:	11/04/2024

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