Provider Demographics
NPI:1194717041
Name:GUMP, STACIE D (MD)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:D
Last Name:GUMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 ROSEMAR CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101
Mailing Address - Country:US
Mailing Address - Phone:304-485-6130
Mailing Address - Fax:304-485-1519
Practice Address - Street 1:2838 PIKE STREET
Practice Address - Street 2:WVU MEDICINE PATRIOT POINTE CAMDEN CLARK PHYSICI CORPOR
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101
Practice Address - Country:US
Practice Address - Phone:304-865-5070
Practice Address - Fax:304-489-4250
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD0060181207Q00000X
WV25319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402740000Medicaid
MD402740000Medicaid
H97588Medicare UPIN
MDI685Medicare PIN