Healthcare Provider Details

I. General information

NPI: 1407068851
Provider Name (Legal Business Name): JOULE N STEVENSON MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12277 DE PAUL DR SUITE 406
BRIDGETON MO
63044-2516
US

IV. Provider business mailing address

12277 DE PAUL DR SUITE 406
BRIDGETON MO
63044-2516
US

V. Phone/Fax

Practice location:
  • Phone: 314-731-7844
  • Fax: 314-731-3296
Mailing address:
  • Phone: 314-731-7844
  • Fax: 314-731-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2002019263
License Number StateMO

VIII. Authorized Official

Name: DR. JOULE N STEVENSON
Title or Position: PHYSICIAN OWNER
Credential: M.D.
Phone: 314-731-7844