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NPI Code Detail

MEDICARE: DR. JON CHARLES STEPHENSON MD

MEDICARE: DR. JON CHARLES STEPHENSON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician21317WI

General Provider Information

NPI Number : 1114978236
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JON CHARLES STEPHENSON MD
Provider Business Mailing Address
First Line : 109 N 28TH ST E
Second Line :
City : SUPERIOR
State : WI
Zip : 54880-6548
Country : US
Telephone Number : 715-395-3930
Fax Number :
Provider Business Practice Location Address
First Line : 109 N 28TH ST E
Second Line :
City : SUPERIOR
State : WI
Zip : 54880-6548
Country : US
Telephone Number : 715-395-3930
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/13/2006
Last Update Date : 10/19/2007

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