Basic Information
| Provider Information | |||||||||
| NPI: | 1477644722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 219 ASHLEY PLACE RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292299627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032344416 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 STUART ST | ||||||||
| Address2: | MONCRIEF ARMY COMMUNITY HOSPITAL/CREDENTIALS | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292075700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037512618 | ||||||||
| FaxNumber: | 8037512689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 171000000X | LD00002104 | WA | Y | Other Service Providers | Military Health Care Provider |
No ID Information.