Provider Demographics
NPI:1639147929
Name:STACEY, ROBERT R (ATC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:R
Last Name:STACEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8922 N WISNER ST
Mailing Address - Street 2:APT. GE
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1764
Mailing Address - Country:US
Mailing Address - Phone:815-353-5579
Mailing Address - Fax:
Practice Address - Street 1:6000 W TOUHY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-1275
Practice Address - Country:US
Practice Address - Phone:773-774-4291
Practice Address - Fax:773-774-4527
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine