Provider Demographics
NPI:1669615332
Name:COBB, STACEY M (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:COBB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:STREETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 210
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-6598
Practice Address - Fax:803-434-1920
Is Sole Proprietor?:No
Enumeration Date:2009-04-10
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD 350392080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC350391Medicaid
SC350391Medicaid