MEDICARE: MR. GREGORY BROMMETT STEPHENSON PA-C

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	363A00000X	Physician Assistant	085-000611	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200153400	OTHER	IN	INDIANA WELFARE

General Provider Information

NPI Number	:	1437363736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GREGORY BROMMETT STEPHENSON PA-C

Provider Business Mailing Address
First Line	:	6852 S OGLESBY AVE
Second Line	:	#2
City	:	CHICAGO
State	:	IL
Zip	:	60649-1324
Country	:	US
Telephone Number	:	773-363-6985
Fax Number	:	773-363-6985

Provider Business Practice Location Address
First Line	:	4320 FIR ST
Second Line	:	SUITE 210
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3052
Country	:	US
Telephone Number	:	219-836-5464
Fax Number	:	219-228-4777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	04/25/2008

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