Healthcare Provider Details

I. General information

NPI: 1477644722
Provider Name (Legal Business Name): MR. MARC J STEVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 STUART ST MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS
COLUMBIA SC
29207-5700
US

IV. Provider business mailing address

219 ASHLEY PLACE RD
COLUMBIA SC
29229-9627
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-2618
  • Fax: 803-751-2689
Mailing address:
  • Phone: 803-234-4416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberLD00002104
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: