Provider Demographics
NPI:1962521716
Name:EDWARD T STEVENS MD SC
Entity type:Organization
Organization Name:EDWARD T STEVENS MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:TERRANCE
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-656-0006
Mailing Address - Street 1:600 52ND STREET
Mailing Address - Street 2:SUITE 240
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3423
Mailing Address - Country:US
Mailing Address - Phone:262-656-0006
Mailing Address - Fax:262-656-0005
Practice Address - Street 1:600 52ND STREET
Practice Address - Street 2:SUITE 240
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3423
Practice Address - Country:US
Practice Address - Phone:262-656-0006
Practice Address - Fax:262-656-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI229190202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30305400Medicaid
B56876Medicare UPIN
WI30305400Medicaid