Provider Demographics
NPI:1407955214
Name:MCMURTRY, STACIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:A
Last Name:MCMURTRY
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 1:9800 SHELBYVILLE RD
Mailing Address - Street 2:STE 220
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2992
Mailing Address - Country:US
Mailing Address - Phone:502-429-8585
Mailing Address - Fax:855-656-7325
Practice Address - Street 1:1800 HOLLISTER DR STE 210
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5266
Practice Address - Country:US
Practice Address - Phone:847-549-7711
Practice Address - Fax:847-549-1020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036092889207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG78888Medicare UPIN