Basic Information
| Provider Information | |||||||||
| NPI: | 1124067368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2809 DENNY AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288095510 | ||||||||
| FaxNumber: | 2288095519 | ||||||||
| Practice Location | |||||||||
| Address1: | 2809 DENNY AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395815301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288095510 | ||||||||
| FaxNumber: | 2288095519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 20203 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | 12159 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51028907 | 01 | AL | BCBS | OTHER | 51077048 | 01 | AL | BCBS | OTHER | 51593818 | 01 | AL | BCBS - 954 NAVCO RD | OTHER | 04-11062 | 01 | AL | UNITED HEALTHCARE | OTHER | 000028907 | 05 | AL | MEDICAID | 110144785 | 01 | AL | RAILROAD MEDICARE PTAN | OTHER | 00121547 | 05 | MS | MEDICAID | 263706500 | 05 | FL | MEDICAID |