Provider Demographics
NPI:1124174198
Name:WARING, STACEY (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WARING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:CONDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:3950 KRESGE WAY
Practice Address - Street 2:SUITE 303
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4637
Practice Address - Country:US
Practice Address - Phone:502-896-6696
Practice Address - Fax:502-896-1795
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50018552OtherPASSPORT
KY6405288900Medicaid
H61302Medicare UPIN
KY6405288900Medicaid