MEDICARE: STACEY DROTT VANCE MD

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	207Q00000X	Family Medicine Physician	MD33966	TN

General Provider Information

NPI Number	:	1952300790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY DROTT VANCE MD

Provider Business Mailing Address
First Line	:	120 MAIN ST
Second Line	:
City	:	PORTLAND
State	:	TN
Zip	:	37148-1218
Country	:	US
Telephone Number	:	615-323-8873
Fax Number	:	615-323-8874

Provider Business Practice Location Address
First Line	:	120 MAIN ST
Second Line	:
City	:	PORTLAND
State	:	TN
Zip	:	37148-1218
Country	:	US
Telephone Number	:	615-323-8873
Fax Number	:	615-323-8874

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

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	07/08/2007

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