Provider Demographics
NPI:1194389155
Name:THOMAS, STACEY ELENGICKAL
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ELENGICKAL
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ELIZABETH
Other - Last Name:ELENGICKAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MBA
Mailing Address - Street 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:484-337-1632
Mailing Address - Fax:
Practice Address - Street 1:130 S BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3121
Practice Address - Country:US
Practice Address - Phone:484-337-4097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD478546207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine