Basic Information
Provider Information | |||||||||
NPI: | 1972675106 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STACI R YOUNG MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 621 | ||||||||
Address2: |   | ||||||||
City: | EDWARDSVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 620250621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186929640 | ||||||||
FaxNumber: | 6186929643 | ||||||||
Practice Location | |||||||||
Address1: | 3 SUNSET HILLS PROFESSIONAL CTR STE D | ||||||||
Address2: |   | ||||||||
City: | EDWARDSVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 620253760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6186550015 | ||||||||
FaxNumber: | 6186550016 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/14/2006 | ||||||||
LastUpdateDate: | 02/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | STACI | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 6186550015 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.