=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235118498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERI GLEE STEVENSON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2006
-----------------------------------------------------
Last Update Date | 08/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 BLAKE AVE STE 201
-----------------------------------------------------
City | GLENWOOD SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81601-4286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-947-9999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 CLIFFROSE WAY
-----------------------------------------------------
City | GLENWOOD SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81601-6705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-579-6246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 39689
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0063531
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------