Basic Information
| Provider Information | |||||||||
| NPI: | 1841279767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 220 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862411 | ||||||||
| FaxNumber: | 5736868452 | ||||||||
| Practice Location | |||||||||
| Address1: | 686 LESTER ST | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862411 | ||||||||
| FaxNumber: | 5736868452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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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 | 207Q00000X | 110842 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 245195409 | 05 | MO | MEDICAID | 142268003 | 05 | AR | MEDICAID |