Provider Demographics
NPI:1346214673
Name:LYNCH, STACY L (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:LYNCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:262-306-2964
Practice Address - Street 1:1700 W PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9795
Practice Address - Country:US
Practice Address - Phone:262-334-3451
Practice Address - Fax:262-306-2964
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51189208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346214673Medicaid
MN188617700Medicaid
MN250000683Medicare ID - Type Unspecified
WI025267025Medicare PIN
P00376149Medicare ID - Type UnspecifiedRAILROAD
I40563Medicare UPIN