Provider Demographics
NPI:1972675106
Name:STACI R YOUNG MD PC
Entity type:Organization
Organization Name:STACI R YOUNG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:R
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-655-0015
Mailing Address - Street 1:PO BOX 621
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0621
Mailing Address - Country:US
Mailing Address - Phone:618-692-9640
Mailing Address - Fax:618-692-9643
Practice Address - Street 1:3 SUNSET HILLS PROFESSIONAL CTR STE D
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3760
Practice Address - Country:US
Practice Address - Phone:618-655-0015
Practice Address - Fax:618-655-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty