Provider Demographics
NPI:1972827400
Name:KRUETH, STACY (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KRUETH
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 1:5671 PEACHTREE DUNWOODY RD STE 610
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5013
Mailing Address - Country:US
Mailing Address - Phone:404-257-1415
Mailing Address - Fax:404-851-1649
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD STE 610
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5013
Practice Address - Country:US
Practice Address - Phone:404-257-1415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118109207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB238319Medicare PIN