Healthcare Provider Details

I. General information

NPI: 1316152127
Provider Name (Legal Business Name): STACEY L. PETERSON-CARMICHAEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY L. PETERSON

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-4500
  • Fax: 336-713-4501
Mailing address:
  • Phone: 336-716-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number2004-00573
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number01073456
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number01073456
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number01073456
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004-00573
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: