Provider Demographics
NPI:1881310191
Name:BURGESS, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255-0067
Mailing Address - Country:US
Mailing Address - Phone:406-768-2180
Mailing Address - Fax:
Practice Address - Street 1:107 H ST
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255-7817
Practice Address - Country:US
Practice Address - Phone:406-768-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5646292085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging