Provider Demographics
NPI:1235235003
Name:MEMBERG, STACEY JP (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JP
Last Name:MEMBERG
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:PO BOX 8792
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8792
Mailing Address - Country:US
Mailing Address - Phone:300-723-7005
Mailing Address - Fax:330-723-4854
Practice Address - Street 1:4015 MEDINA RD STE 50
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5970
Practice Address - Country:US
Practice Address - Phone:330-723-7005
Practice Address - Fax:330-723-4854
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077164208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2196565Medicaid