=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043524549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADOMIR D STEVANOVIC MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2010
-----------------------------------------------------
Last Update Date | 07/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2343 N TRIPHAMMER RD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-1092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-266-9100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2343 N TRIPHAMMER RD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-1092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-266-9100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RADOMIR D STEVANOVIC
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 607-266-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------