Healthcare Provider Details

I. General information

NPI: 1841287075
Provider Name (Legal Business Name): MERVIN C STOVER III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 RIDGE RD
MUNSTER IN
46321-1647
US

IV. Provider business mailing address

PO BOX 1000
DYER IN
46311-0800
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-5738
  • Fax: 219-836-5782
Mailing address:
  • Phone: 219-864-2107
  • Fax: 219-864-2649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01024290A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: