Provider Demographics
NPI:1336291038
Name:BLACK, STACEY RAE (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:RAE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY RAE
Other - Middle Name:BLACK
Other - Last Name:ARMSTRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:717 PAINT ROCK FERRY RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-5040
Mailing Address - Country:US
Mailing Address - Phone:369-293-0988
Mailing Address - Fax:
Practice Address - Street 1:990 OAK RIDGE TPKE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6976
Practice Address - Country:US
Practice Address - Phone:866-730-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ459842085R0202X, 2085R0204X
TN648052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty