=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003870379
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE ROBERT STEVENS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2006
-----------------------------------------------------
Last Update Date | 11/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1806 SUMMIT AVE STE 300
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23230-4339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-362-2227
-----------------------------------------------------
Fax | 804-362-2228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2151 S STARLIGHT DR
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-5827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-929-8682
-----------------------------------------------------
Fax | 804-362-2228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | M-15170
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 34578
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 0101244688
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD.MD.61113530
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------