=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083644306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM STEPHAN, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 10/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4080 DELAWARE AVE
-----------------------------------------------------
City | TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14150-6848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-875-7399
-----------------------------------------------------
Fax | 716-692-4342
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 92336
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14692-0336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-692-3302
-----------------------------------------------------
Fax | 716-692-4342
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM STEPHAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 716-875-7399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------