Healthcare Provider Details

I. General information

NPI: 1265497879
Provider Name (Legal Business Name): STACI M RESNICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 MIDDLE ST SUITE 1100
FALL RIVER MA
02721-1778
US

IV. Provider business mailing address

851 MIDDLE ST SUITE 1100
FALL RIVER MA
02721-1778
US

V. Phone/Fax

Practice location:
  • Phone: 508-324-6800
  • Fax: 508-674-5440
Mailing address:
  • Phone: 508-324-6800
  • Fax: 508-674-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number156346
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: