Provider Demographics
NPI:1083623250
Name:WEDEL, STACI L (MD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:L
Last Name:WEDEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 A AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5057
Mailing Address - Country:US
Mailing Address - Phone:319-368-9300
Mailing Address - Fax:319-368-5690
Practice Address - Street 1:855 A AVE NE
Practice Address - Street 2:SUITE 300
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5057
Practice Address - Country:US
Practice Address - Phone:319-368-9300
Practice Address - Fax:319-368-5690
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS31367208000000X
IA37934208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1083623250Medicaid
KS102549OtherHPK
KS244545OtherCOVENTRY
KS104840OtherBCBS
KS12149415OtherMULTIPLAN
KS200333240AMedicaid
KS14746OtherPHS
KS104840Medicare ID - Type Unspecified
IA1083623250Medicaid
KS102549OtherHPK