Provider Demographics
NPI:1992721799
Name:WEIL, STACIE (MD)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WEIL
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:1155 EAST MOUNTAIN BLVD.
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-808-7916
Practice Address - Fax:570-808-6006
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-086657207V00000X, 207VE0102X
PAMD043404L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014188520006Medicaid
OH364121OtherWELLCARE
OH000000221335OtherUNISON
OH2586652Medicaid
OH751026OtherBUCKEYE
OH000000509189OtherANTHEM
OH4406587OtherAETNA
OH4406587OtherAETNA
OHWE4166591Medicare PIN
OH751026OtherBUCKEYE