Provider Demographics
NPI:1548587785
Name:KASSUTTO, STACEY M (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:KASSUTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MICHELLE
Other - Last Name:BLANCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3400 CIVIC CENTER BLVD FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5161
Mailing Address - Country:US
Mailing Address - Phone:215-662-3202
Mailing Address - Fax:215-349-8432
Practice Address - Street 1:3400 CIVIC CENTER BLVD FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5161
Practice Address - Country:US
Practice Address - Phone:215-662-3202
Practice Address - Fax:215-349-8432
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD447429207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease