Provider Demographics
NPI:1316923824
Name:ROYAL, STACEY Y (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:Y
Last Name:ROYAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 WASHINGTON RD
Mailing Address - Street 2:# 2000
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-2520
Mailing Address - Country:US
Mailing Address - Phone:419-819-0488
Mailing Address - Fax:412-202-5375
Practice Address - Street 1:1106 OHIO RIVER BLVD
Practice Address - Street 2:# 602
Practice Address - City:SEWICKLEY
Practice Address - State:PA
Practice Address - Zip Code:15143-2048
Practice Address - Country:US
Practice Address - Phone:419-819-0488
Practice Address - Fax:412-202-5375
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079907R207Q00000X, 2083X0100X
MI4301073222207Q00000X, 2083X0100X
PAMD434643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2750876Medicaid
OH2268139Medicaid
PA1022588090001Medicaid
OH2750876Medicaid
OH9334161Medicare PIN
PA147754ZC5FMedicare PIN
OH2268139Medicaid
OH9364911Medicare PIN
OH4059457Medicare PIN