Provider Demographics
NPI:1194964452
Name:STACEY STEFANSKY DPM PLLC
Entity type:Organization
Organization Name:STACEY STEFANSKY DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEFANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-390-5730
Mailing Address - Street 1:PO BOX 300965
Mailing Address - Street 2:
Mailing Address - City:DRAYTON PLAINS
Mailing Address - State:MI
Mailing Address - Zip Code:48330-0965
Mailing Address - Country:US
Mailing Address - Phone:248-390-5730
Mailing Address - Fax:
Practice Address - Street 1:2130 MARSHALL COURT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-4069
Practice Address - Country:US
Practice Address - Phone:248-390-5730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002115261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1053399949Medicaid
MI4856320100OtherBLUE CROSS BLUE SHIELD
MIMI1739Medicare PIN