Provider Demographics
NPI:1356486682
Name:SMITH, STACEY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:SMITH
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4868
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:747 E COUNTY LINE RD STE G
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1082
Practice Address - Country:US
Practice Address - Phone:317-781-7297
Practice Address - Fax:317-781-7271
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064927A208000000X
KYR1083208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200918800Medicaid
IN1102425183OtherANTHEM PTAN