Basic Information
| Provider Information | |||||||||
| NPI: | 1982053435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SAUNDERS | ||||||||
| FirstName: | STACEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424311661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708257200 | ||||||||
| FaxNumber: | 2708257266 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424311661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708256680 | ||||||||
| FaxNumber: | 2708257266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 51663 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 51663 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100501170 | 05 | KY | MEDICAID |