Healthcare Provider Details

I. General information

NPI: 1881673085
Provider Name (Legal Business Name): DOUGLAS S STEVENS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 11/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12701 W 143RD ST SUITE 200
HOMER GLEN IL
60491-7715
US

IV. Provider business mailing address

12701 W 143RD ST SUITE 200
HOMER GLEN IL
60491-7715
US

V. Phone/Fax

Practice location:
  • Phone: 877-694-7722
  • Fax: 815-531-0055
Mailing address:
  • Phone: 877-694-7722
  • Fax: 815-531-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001302
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberIL085-001302
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: