Provider Demographics
NPI:1659485530
Name:SMITH, STACY LEE (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4660 MARYLAND AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-361-8566
Mailing Address - Fax:314-361-3383
Practice Address - Street 1:4660 MARYLAND AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-361-8566
Practice Address - Fax:314-361-3383
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOMD1012122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G30583Medicare UPIN