Basic Information
| Provider Information | |||||||||
| NPI: | 1215049481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D O | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636643 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409893801 | ||||||||
| FaxNumber: | 4409600264 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 KOLBE RD | ||||||||
| Address2: | SUITE 227 | ||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440531654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409603304 | ||||||||
| FaxNumber: | 4409604733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
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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 | 207R00000X | 34-00-3042-S | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0450042 | 05 | OH | MEDICAID | 0236248 | 05 | OH | MEDICAID | 3025372 | 05 | OH | MEDICAID |