Basic Information
| Provider Information | |||||||||
| NPI: | 1902916927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STACHECKI | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 STATE HIGHWAY K | ||||||||
| Address2: | STE 100 | ||||||||
| City: | O'FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362405454 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2630 STATE HIGHWAY K | ||||||||
| Address2: | STE 100 | ||||||||
| City: | O'FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362405454 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2003015153 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208826107 | 05 | MO | MEDICAID |