Provider Demographics
NPI:1649274382
Name:SKELLY, STEPHANIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SKELLY
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 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:723 STATION XING
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1886
Practice Address - Country:US
Practice Address - Phone:618-939-1551
Practice Address - Fax:618-939-1553
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-095296207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036095296Medicaid
ILK01500Medicare PIN
IL036095296Medicaid