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General NPI Number Information
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NPI Number | 1962521716
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Entity Type | Organization
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Legal Business Name | EDWARD T STEVENS MD SC
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 600 52ND STREET SUITE 240
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City | KENOSHA
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State | WI
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Zip | 53140-3423
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Country | US
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Telephone | 262-656-0006
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Fax | 262-656-0005
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Provider Business Mailing Address
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Address Line | 600 52ND STREET SUITE 240
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City | KENOSHA
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State | WI
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Zip | 53140-3423
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Country | US
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Telephone | 262-656-0006
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Fax | 262-656-0005
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. EDWARD TERRANCE STEVENS
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Credential | MD
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Telephone | 262-656-0006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 22919020
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License Number State | WI
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