Basic Information
| Provider Information | |||||||||
| NPI: | 1972750446 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACIP | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53076 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705053076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374702180 | ||||||||
| FaxNumber: | 3374702677 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 AMBASSADOR CAFFERY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374702180 | ||||||||
| FaxNumber: | 3374702677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2008 | ||||||||
| LastUpdateDate: | 12/14/2012 | ||||||||
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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 | 2085R0202X | MD.205841 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2317059 | 05 | LA | MEDICAID |