Healthcare Provider Details

I. General information

NPI: 1053418442
Provider Name (Legal Business Name): WILLIE F STEWART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W HOMER ST
MICHIGAN CITY IN
46360-4358
US

IV. Provider business mailing address

4920 S CORNELL AVE
CHICAGO IL
60615-3014
US

V. Phone/Fax

Practice location:
  • Phone: 219-879-8511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number01025693A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: