Provider Demographics
NPI:1104437797
Name:MEDFORD, STEPHEN T
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:MEDFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 HARTMAN LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7207
Mailing Address - Country:US
Mailing Address - Phone:618-531-3007
Mailing Address - Fax:
Practice Address - Street 1:1017 HARTMAN LN
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-7207
Practice Address - Country:US
Practice Address - Phone:618-531-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider