Provider Demographics
NPI:1851318489
Name:LAFF, STACIE (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:LAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR STE 280
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5363
Mailing Address - Country:US
Mailing Address - Phone:618-257-2800
Mailing Address - Fax:618-257-9802
Practice Address - Street 1:4600 MEMORIAL DR STE 280
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5363
Practice Address - Country:US
Practice Address - Phone:618-257-2800
Practice Address - Fax:618-257-9802
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-092496208000000X
MO103954208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092496-2Medicaid
IL036092496-3Medicaid