Basic Information
| Provider Information | |||||||||
| NPI: | 1831126200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEARSON | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601372 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043047000 | ||||||||
| FaxNumber: | 7043047008 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 VAIL AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043047000 | ||||||||
| FaxNumber: | 7043047008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 200500250 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 200500250 | NC | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 140XN | 01 | NC | BCBS NC | OTHER | 1831126200 | 05 | NC | MEDICAID | 5902724 | 05 | NC | MEDICAID | 5917863 | 05 | NC | MEDICAID | N0025C | 05 | SC | MEDICAID |