Healthcare Provider Details

I. General information

NPI: 1356875777
Provider Name (Legal Business Name): SAMUEL STEVENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-4504
US

IV. Provider business mailing address

9040 JACKSON AVE
JOINT BASE LEWIS-MCCHORD WA
98433
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax:
Mailing address:
  • Phone: 774-200-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD61202822
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101266576
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: