Provider Demographics
NPI:1225007255
Name:BELTZ, STACEY (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BELTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 E SQUARE LAKE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3899
Mailing Address - Country:US
Mailing Address - Phone:248-813-0124
Mailing Address - Fax:248-813-9261
Practice Address - Street 1:2041 E SQUARE LAKE RD
Practice Address - Street 2:STE. 300
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3899
Practice Address - Country:US
Practice Address - Phone:248-813-0124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080F370780OtherBCBSM
MI080F370780OtherBCBSM
MI0F37078070Medicare ID - Type Unspecified