Provider Demographics
NPI:1619071115
Name:BULL, STACY SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:SUZANNE
Last Name:BULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:SUZANNE
Other - Last Name:DUCKLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:804 SERVICE RD
Mailing Address - Street 2:# A109F
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-884-2976
Mailing Address - Fax:517-432-3928
Practice Address - Street 1:463 E CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7500
Practice Address - Country:US
Practice Address - Phone:517-884-6502
Practice Address - Fax:517-355-9265
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070974207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4546883Medicaid
MI0803310501OtherBCBS INDIVIDUAL PIN
MI1619071115Medicaid
MI0803310501OtherBCBS INDIVIDUAL PIN
MIN37250019Medicare ID - Type Unspecified
MI1619071115Medicaid