Provider Demographics
NPI:1720309057
Name:OLLIFF, STACY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MICHAEL
Last Name:OLLIFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 HIGHWAY 155 N
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-4846
Mailing Address - Country:US
Mailing Address - Phone:678-490-0341
Mailing Address - Fax:678-490-0349
Practice Address - Street 1:2200 HIGHWAY 155 N
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-4846
Practice Address - Country:US
Practice Address - Phone:678-490-0341
Practice Address - Fax:678-490-0349
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine