Basic Information
Provider Information | |||||||||
NPI: | 1386021970 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEVENSON | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: | WARD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 600726 | ||||||||
Address2: |   | ||||||||
City: | JACKSONVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 322600726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 900 E BROADWAY AVE | ||||||||
Address2: |   | ||||||||
City: | BISMARCK | ||||||||
State: | ND | ||||||||
PostalCode: | 585014520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7015307000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2015 | ||||||||
LastUpdateDate: | 08/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 17528 | ND | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | ME138203 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | ME138203 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 80039 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | ME138203 | 01 | FL | FLORIDA MEDICAL LICENSE | OTHER | FS9314547 | 01 |   | DEA | OTHER | PT17528 | 01 | ND | NORTH DAKOTA BOARD OF MEDICINE | OTHER |