Basic Information
| Provider Information | |||||||||
| NPI: | 1831127463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 HOLLYWOOD ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ST JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694290900 | ||||||||
| FaxNumber: | 2694080996 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694290900 | ||||||||
| FaxNumber: | 2694080996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 06/27/2017 | ||||||||
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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 | 208600000X | 4301404254 | MI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 27-0381199 | 01 | MI | GROUP TAX ID | OTHER | 1538397120 | 01 | MI | GROUP NPI | OTHER | BS1147835 | 01 | MI | DEA | OTHER | 0201109862 | 01 | MI | BLUE CROSS PIN | OTHER | 1831127463 | 05 | MI | MEDICAID | MI2051 | 01 | MI | GROUP MEDICARE PTAN | OTHER |