Healthcare Provider Details

I. General information

NPI: 1417240953
Provider Name (Legal Business Name): COLLIER STEPHENS PACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2011
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 N CHURCH ST STE 100
GREENSBORO NC
27401-1447
US

IV. Provider business mailing address

PO BOX 19653
SPRINGFIELD IL
62794-9653
US

V. Phone/Fax

Practice location:
  • Phone: 336-890-2210
  • Fax:
Mailing address:
  • Phone: 804-828-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036143109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: