Healthcare Provider Details

I. General information

NPI: 1972675106
Provider Name (Legal Business Name): STACI R YOUNG MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SUNSET HILLS PROFESSIONAL CTR STE D
EDWARDSVILLE IL
62025-3760
US

IV. Provider business mailing address

PO BOX 621
EDWARDSVILLE IL
62025-0621
US

V. Phone/Fax

Practice location:
  • Phone: 618-655-0015
  • Fax: 618-655-0016
Mailing address:
  • Phone: 618-692-9640
  • Fax: 618-692-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: STACI R YOUNG
Title or Position: OWNER
Credential: MD
Phone: 618-655-0015