Provider Demographics
NPI:1649210832
Name:SMITH, STACEY A (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572-4234
Mailing Address - Country:US
Mailing Address - Phone:218-863-6100
Mailing Address - Fax:
Practice Address - Street 1:211 E MILL ST
Practice Address - Street 2:
Practice Address - City:PELICAN RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56572-4234
Practice Address - Country:US
Practice Address - Phone:218-863-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0107063OtherMEDICA #
MN20696OtherNDBS #
MN677682500Medicaid
MN1280970OtherAMERICA'S PPO/ARAZ #
MN43G89SMOtherMNBS #
MN0107064OtherMEDICA #
MN142065OtherUCARE #
MNDA9031028234OtherPREFERRED ONE #
MN11146Medicaid
MNHP38211OtherHEALTHPARTNERS #
MNMN100045OtherLHS/BANNERHEALTH #
MNDA9031028234OtherPREFERRED ONE #
MN20696OtherNDBS #
MN142065OtherUCARE #