Provider Demographics
NPI:1447206891
Name:GREENE, STACIA LEE (MD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:LEE
Last Name:GREENE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:L
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4405 E 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4187
Practice Address - Country:US
Practice Address - Phone:605-332-2883
Practice Address - Fax:605-328-9001
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41176207Q00000X
SD4625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP00008248Medicare PIN
SD080194615Medicare PIN
G36303Medicare UPIN
SDS40998Medicare PIN