Provider Demographics
NPI:1346201274
Name:ROBERTSON, STACEY A (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:ROBERTSON
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:PA
Mailing Address - Zip Code:15923-0038
Mailing Address - Country:US
Mailing Address - Phone:724-676-4709
Mailing Address - Fax:724-676-4752
Practice Address - Street 1:802 MCKINLEY ST
Practice Address - Street 2:BOLIVAR MEDICAL CENTER
Practice Address - City:BOLIVAR
Practice Address - State:PA
Practice Address - Zip Code:15923
Practice Address - Country:US
Practice Address - Phone:724-676-4709
Practice Address - Fax:724-676-4752
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAO5004404L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101206165Medicaid
155705Medicare PIN
E70754Medicare UPIN