Basic Information
Provider Information | |||||||||
NPI: | 1417375197 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEVENS | ||||||||
FirstName: | ERICA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 776879 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022725063 | ||||||||
FaxNumber: | 5022725339 | ||||||||
Practice Location | |||||||||
Address1: | 411 E CHESTNUT ST | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402021713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025884940 | ||||||||
FaxNumber: | 5025887712 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2014 | ||||||||
LastUpdateDate: | 10/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 53456 | KY | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 390200000X | MT212692 | PA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 390200000X | MD461129 | PA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2080P0214X | 53456 | KY | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
ID | Type | State | Issuer | Description | MT212692 | 01 | PA | MEDICAL TRAINING LICENSE | OTHER | MD461129 | 01 | PA | FULL UNRESTRICTED MEDICAL LICENSE | OTHER |