Provider Demographics
NPI:1235331596
Name:CHAMBERLAIN, STACEY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYNN
Last Name:CHAMBERLAIN
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 1:419 N HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2336
Mailing Address - Country:US
Mailing Address - Phone:773-510-4180
Mailing Address - Fax:
Practice Address - Street 1:808 S WOOD ST
Practice Address - Street 2:RM. 471
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7300
Practice Address - Country:US
Practice Address - Phone:312-413-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117846207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK46337Medicare PIN
I73823Medicare UPIN