Provider Demographics
NPI:1336436435
Name:GREGORY, STACIE RENEE (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:RENEE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:301 N 8TH ST
Mailing Address - Street 2:PO BOX 19662
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-1041
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-0253
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:PAV 5B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-0253
Is Sole Proprietor?:No
Enumeration Date:2011-07-09
Last Update Date:2020-10-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-142803207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology