Healthcare Provider Details

I. General information

NPI: 1336368547
Provider Name (Legal Business Name): STACEY ANN SOUTH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 UNIVERSITY PKWY UNIT 102
SARASOTA FL
34243-4271
US

IV. Provider business mailing address

367 S. GULPH ROAD ATT: IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-746-7507
  • Fax: 941-351-2668
Mailing address:
  • Phone: 941-746-7507
  • Fax: 941-351-3668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number236615
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberME101589
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: