Healthcare Provider Details

I. General information

NPI: 1457453375
Provider Name (Legal Business Name): CHARLES B STACY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E 98TH ST 7TH FLOOR
NEW YORK NY
10029-6501
US

IV. Provider business mailing address

5 E 98TH ST 7TH FLOOR
NEW YORK NY
10029-6501
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-0022
  • Fax: 212-241-4350
Mailing address:
  • Phone: 212-241-0022
  • Fax: 212-241-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number137377
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: