MEDICARE: E KENT STEVENSON MD PC

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
1	2084P0800X	Psychiatry Physician	0415789	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04563147	OTHER	KS	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1275857575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	E KENT STEVENSON MD PC

Provider Business Mailing Address
First Line	:	5200 W 94TH TER
Second Line	:	SUITE 105
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2522
Country	:	US
Telephone Number	:	913-649-5567
Fax Number	:	913-649-7563

Provider Business Practice Location Address
First Line	:	5200 W 94TH TER
Second Line	:	SUITE 105
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2522
Country	:	US
Telephone Number	:	913-649-5567
Fax Number	:	913-649-7563

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDWARD KENT STEVENSON
Credential	:	M.D.
Telephone Number	:	913-649-5567

Provider Enumeration Date	:	03/16/2010
Last Update Date	:	04/22/2010

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Directions to “E KENT STEVENSON MD PC ” Practice Location

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