Provider Demographics
NPI:1376578229
Name:HERTZ, STACEY A (PAAA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:HERTZ
Suffix:
Gender:F
Credentials:PAAA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANNE
Other - Last Name:FOREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:550 PEACHTREE ST NE BLDG 2ND
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2247
Mailing Address - Country:US
Mailing Address - Phone:404-686-2316
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1013
Practice Address - Country:US
Practice Address - Phone:404-778-4852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002690367H00000X
GA2690207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10000327AMedicaid
GA10000327AMedicaid
GA43ZCBCR98Medicare ID - Type Unspecified