Healthcare Provider Details

I. General information

NPI: 1114904729
Provider Name (Legal Business Name): TYLER K STEVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4095 MEADOWBROOK BLVD
UNIVERSITY HEIGHTS OH
44118-3854
US

IV. Provider business mailing address

9500 EUCLID AVE # A31
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-371-4171
  • Fax:
Mailing address:
  • Phone: 216-445-1996
  • Fax: 216-444-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-081031
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number81031
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: