Basic Information
| Provider Information | |||||||||
| NPI: | 1689069825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | CAIN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAIN | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 1215 LEE ST | ||||||||
| Address2: | BOX 800744 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349241931 | ||||||||
| FaxNumber: | 4342435770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2015 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101272605 | VA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RI0200X | 0101272605 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.