Provider Demographics
NPI:1417497819
Name:SHIVELY, STEPHEN RICHARD (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RICHARD
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6737 VAIL CT
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-0139
Mailing Address - Country:US
Mailing Address - Phone:317-341-0613
Mailing Address - Fax:
Practice Address - Street 1:1 MEMORIAL SQ STE 2100
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1380
Practice Address - Country:US
Practice Address - Phone:317-477-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007116A207XX0005X
VA0102207029207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program