Provider Demographics
NPI:1417704453
Name:FORCUM, STEPHEN MICHAEL
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:FORCUM
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 1:39 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2413
Mailing Address - Country:US
Mailing Address - Phone:760-884-9897
Mailing Address - Fax:
Practice Address - Street 1:1606 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2706
Practice Address - Country:US
Practice Address - Phone:812-238-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10004446A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant