Basic Information
| Provider Information | |||||||||
| NPI: | 1225470602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W JACKSON STREET | ||||||||
| Address2: | DBA SIH MEDICAL GROUP ANESTHESIOLOGY | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6185290449 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 W JACKSON STREET | ||||||||
| Address2: | DBA SIH MEDICAL GROUP ANESTHESIOLOGY | ||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185490721 | ||||||||
| FaxNumber: | 6185290449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2013 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036146722 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 214881 | 01 | IL | MULTI-SPECIALTY GROUP PTAN | OTHER |