Provider Demographics
NPI:1093761702
Name:WING, STACEY W (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:W
Last Name:WING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850489
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36685-0489
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-631-3361
Practice Address - Street 1:610 PROVIDENCE PARK DR E
Practice Address - Street 2:BLDG 1 - SUITE 102
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4622
Practice Address - Country:US
Practice Address - Phone:251-378-3900
Practice Address - Fax:251-378-3901
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL21251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL117354Medicaid
AL511-01630OtherBLUE CROSS BLUE SHIELD
AL511-01630OtherBLUE CROSS BLUE SHIELD
H13822Medicare UPIN