Provider Demographics
NPI:1215939426
Name:REMINE, STEPHEN GORDON (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:GORDON
Last Name:REMINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 RIVERSIDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:540-983-8212
Practice Address - Street 1:3 RIVERSIDE CIRCLE
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:540-983-8212
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076893208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI424506610Medicaid
MI4301076893OtherCONTROLLED SUBSTANCE
VA010174767Medicaid
VA010174759Medicaid
VA010174767Medicaid
VA010174759Medicaid
MI424506610Medicaid
VAP00253631Medicare PIN