Basic Information
| Provider Information | |||||||||
| NPI: | 1568587293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | DEPT. OF CREDENTIALING | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015524 | ||||||||
| FaxNumber: | 4106018946 | ||||||||
| Practice Location | |||||||||
| Address1: | 2435 W BELVEDERE AVE | ||||||||
| Address2: | SUITE 42 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106015547 | ||||||||
| FaxNumber: | 4106015835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | D65426 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | D65426 | MD | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | D65426 | MD | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00464112 | 01 | MD | MEDICARE R/R PROVIDER # | OTHER | CC1923 | 01 | MD | MEDICARE R/R GROUP # | OTHER |