Basic Information
| Provider Information | |||||||||
| NPI: | 1043246838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2801 N GANTENBEIN AVE | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS, LEGACY EMANUEL HOSPITAL | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034132402 | ||||||||
| FaxNumber: | 5034132566 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 N GANTENBEIN AVE | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS, LEGACY EMANUEL HOSPITAL | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034132402 | ||||||||
| FaxNumber: | 5034132566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 06/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD27853 | OR | Y | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 046652 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 270994 | 05 | OR | MEDICAID | 000917936K | 05 | GA | MEDICAID | 8155160 | 05 | WA | MEDICAID |