Basic Information
Provider Information | |||||||||
NPI: | 1740382548 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEVENS | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 204 S ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | SAINT CROIX FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 540249449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154833221 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 204 S ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | SAINT CROIX FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 540249449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154833221 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2006 | ||||||||
LastUpdateDate: | 03/19/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 45175 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00017813 | 01 |   | RAILROAD | OTHER | 091K8ST | 01 | MN | BLUE CROSS MN PRO FEE | OTHER | 34374400 | 05 | WI |   | MEDICAID | HP38556 | 01 |   | HEALTHPARTNERS | OTHER | 091K7SY | 01 | MN | BLUE CROSS MN FACILITY | OTHER | 0405623 | 01 |   | MEDICA | OTHER | NA9031040062 | 01 |   | PREFERREDONE | OTHER |