Provider Demographics
NPI:1164472312
Name:MCKELVEY, STACEY L (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:MCKELVEY
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 1:200 FOX GLEN CT
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-1809
Mailing Address - Country:US
Mailing Address - Phone:847-382-7165
Mailing Address - Fax:847-713-8160
Practice Address - Street 1:200 FOX GLEN CT
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-1809
Practice Address - Country:US
Practice Address - Phone:847-382-7165
Practice Address - Fax:847-713-8160
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23379207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136563OtherSTATE LICENSE
IL036136563OtherSTATE LICENSE
NE279159Medicare ID - Type Unspecified