Healthcare Provider Details

I. General information

NPI: 1902883481
Provider Name (Legal Business Name): STEVAN I HIMMELSTEIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 UNION AVE STE 965
MEMPHIS TN
38104
US

IV. Provider business mailing address

P O BOX 1000 DEPT 960
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-435-8550
  • Fax: 901-516-0933
Mailing address:
  • Phone: 901-435-8550
  • Fax: 901-516-0933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number12664
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20638
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number12664
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number20638
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: