Provider Demographics
NPI:1265870695
Name:BENNIS, STACEY ANNE (MD, CAQ-SM)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANNE
Last Name:BENNIS
Suffix:
Gender:F
Credentials:MD, CAQ-SM
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ANNE
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, CAQ-SM
Mailing Address - Street 1:2160 S 1ST AVE STE 1700
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:888-584-7888
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE STE 1700
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:888-584-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-063353208100000X
IL0361461202081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation