Healthcare Provider Details

I. General information

NPI: 1760149637
Provider Name (Legal Business Name): STEWARD MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2021
Last Update Date: 11/26/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N WICKHAM RD STE 311
MELBOURNE FL
32935-8661
US

IV. Provider business mailing address

9 GALEN ST
WATERTOWN MA
02472-4515
US

V. Phone/Fax

Practice location:
  • Phone: 321-785-1630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY MARIE GUAY
Title or Position: PRESIDENT OF SMG
Credential:
Phone: 617-562-7070