Provider Demographics
NPI:1992751754
Name:STUCKY, FRED SIMS III (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:SIMS
Last Name:STUCKY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8160
Mailing Address - Country:US
Mailing Address - Phone:207-621-4680
Mailing Address - Fax:
Practice Address - Street 1:35 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8160
Practice Address - Country:US
Practice Address - Phone:207-621-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000175672086S0129X
MEMD277942086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051514735Medicaid
AL126147Medicaid
AL51514735STUOtherBLUE CROSS BLUE SHIELD
AL511-11831OtherBCBS-AL
ALP00000016OtherMEDICARE RAILROAD
AL051514735Medicaid
ALP00000016OtherMEDICARE RAILROAD
F75444Medicare UPIN