Provider Demographics
NPI:1972582302
Name:SOMERS, STEPHANIE (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:SOMERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5082 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1557
Mailing Address - Country:US
Mailing Address - Phone:269-381-0118
Mailing Address - Fax:269-381-4610
Practice Address - Street 1:5082 LOVERS LN
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1557
Practice Address - Country:US
Practice Address - Phone:269-381-0118
Practice Address - Fax:269-381-4610
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1231911OtherPHP
MI3378353Medicaid
MIP61269OtherBLUE CHOICE
MI3503903762OtherBLUE CROSS PIN
MI4301070332OtherSTATE LICENSE
MI4301070332OtherSTATE LICENSE
MI3378353Medicaid