Basic Information
| Provider Information | |||||||||
| NPI: | 1164462024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | MERRILYN | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080962739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566864300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 KENYON AVE | ||||||||
| Address2: | |||||||||
| City: | WAKEFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028794216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017828000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD05994 | RI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD05994 | RI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 7056701 | 05 | RI | MEDICAID |