Provider Demographics
NPI:1720079981
Name:ANDERSON, STACIA S (MD)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:S
Last Name:ANDERSON
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 1:1900 CENTRACARE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44297207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1030414OtherPREFERRED ONE
1855107OtherFIRST HEALTH PLAN
55G63ANOtherBLUE CROSS BLUE SHIELD
COMPOtherMMSI
1545844OtherARAZ GROUP AMERICAS PPO
C11369OtherRR MEDICARE
COMPOtherONE HEALTH PLAN GREAT WES
0702359OtherMEDICA HEALTH PLANS
160056138OtherRR MEDICARE
052720300OtherMEDICAL ASSISTANCE MA
HP34883OtherHEALTH PARTNERS
COMPOtherCHAMPUS
141335OtherU CARE
141335OtherU CARE
0702359OtherMEDICA HEALTH PLANS