Provider Demographics
NPI:1386899458
Name:BAUM, STACY A (PA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:BAUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-315-6700
Mailing Address - Fax:630-315-6699
Practice Address - Street 1:552 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177
Practice Address - Country:US
Practice Address - Phone:630-315-6700
Practice Address - Fax:630-315-6699
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003350363AM0700X
IL085003350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400473831OtherINDIVIDUAL MEDICARE
IL920540OtherGROUP MEDICARE