Basic Information
| Provider Information | |||||||||
| NPI: | 1164646089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | JANDA | ||||||||
| MiddleName: | TERESE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E CARPENTER ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627691000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E. CARPENTER | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 12/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 4301083809 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD60073279 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8551186 | 05 | WA | MEDICAID | P00470689 | 01 | MI | RAILROAD MEDICARE | OTHER | 036126564 1 | 05 | IL | MEDICAID |