MEDICARE: DR. STACY FOWLER DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0131X	Foot Surgery Podiatrist	481	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	081AJ	OTHER	NC	BLUE CROSS
3	11453384	OTHER	NC	FIRST HEALTH

General Provider Information

NPI Number	:	1275549479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY FOWLER DPM

Provider Business Mailing Address
First Line	:	1613 SAINT ANDREWS DR
Second Line	:
City	:	MEBANE
State	:	NC
Zip	:	27302-7116
Country	:	US
Telephone Number	:	336-213-3910
Fax Number	:

Provider Business Practice Location Address
First Line	:	1613 SAINT ANDREWS DR
Second Line	:
City	:	MEBANE
State	:	NC
Zip	:	27302-7116
Country	:	US
Telephone Number	:	336-213-3910
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	11/02/2009

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