Provider Demographics
NPI:1992771216
Name:STIVERS, FORDYCE EDWARD (MD)
Entity type:Individual
Prefix:
First Name:FORDYCE
Middle Name:EDWARD
Last Name:STIVERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:F
Other - Middle Name:EDWARD
Other - Last Name:STIVERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:175 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2670
Mailing Address - Country:US
Mailing Address - Phone:309-647-0201
Mailing Address - Fax:309-649-5302
Practice Address - Street 1:175 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2670
Practice Address - Country:US
Practice Address - Phone:309-647-0201
Practice Address - Fax:309-649-5302
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005013768207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1780692087OtherCLINIC NPI#
B90745Medicare UPIN