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General NPI Number Information
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NPI Number | 1306147962
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Entity Type | Organization
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Legal Business Name | STACEY GILL DO
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Dates
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Enumeration Date | 11/12/2010
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Last Update Date | 11/12/2010
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Provider Practice Location Address
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Address Line | 3084 TROPICAIRE BLVD
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City | NORTH PORT
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State | FL
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Zip | 34286-7117
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Country | US
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Telephone | 941-484-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 3084 TROPICAIRE BLVD
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City | NORTH PORT
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State | FL
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Zip | 34286-7117
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Country | US
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Telephone | 941-484-1600
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. STACEY BUSHNELL GILL
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Credential | D.O.
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Telephone | 941-484-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS8937
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License Number State | FL
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