Provider Demographics
NPI:1669476933
Name:BARTELL, STACEY LYN (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYN
Last Name:BARTELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15990 W 9 MILE RD
Mailing Address - Street 2:STE 210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4826
Mailing Address - Country:US
Mailing Address - Phone:248-849-4226
Mailing Address - Fax:248-849-4240
Practice Address - Street 1:210 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-2048
Practice Address - Country:US
Practice Address - Phone:248-437-1744
Practice Address - Fax:248-437-3245
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301070166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI433638510Medicaid
MI0F36020091Medicare ID - Type Unspecified
MIH24177Medicare UPIN