Provider Demographics
NPI:1336368547
Name:SOUTH, STACEY ANN (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:SOUTH
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 1:367 S. GULPH ROAD
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3121
Mailing Address - Country:US
Mailing Address - Phone:941-746-7507
Mailing Address - Fax:941-351-3668
Practice Address - Street 1:3425 UNIVERSITY PKWY UNIT 102
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-4271
Practice Address - Country:US
Practice Address - Phone:941-746-7507
Practice Address - Fax:941-351-2668
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236615208D00000X
FLME101589207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI14778Medicare UPIN