Provider Demographics
NPI:1295152189
Name:GOEDTEL BIRR, STACEE LYNN (DO)
Entity type:Individual
Prefix:DR
First Name:STACEE
Middle Name:LYNN
Last Name:GOEDTEL BIRR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:STACEE
Other - Middle Name:LYNN
Other - Last Name:GOEDTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:853 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:229 S MORRISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5725
Practice Address - Country:US
Practice Address - Phone:920-832-2783
Practice Address - Fax:920-832-2635
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI65320-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program