Healthcare Provider Details

I. General information

NPI: 1144286188
Provider Name (Legal Business Name): STACY LYNN GENERALOVICH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 MARKET ST STE 2100
BOARDMAN OH
44512-3457
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-746-8040
  • Fax: 330-746-8025
Mailing address:
  • Phone: 330-746-8040
  • Fax: 330-746-8025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.008077
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: