MEDICARE: STACEY L. PETERSON-CARMICHAEL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0214X	Pediatric Pulmonology Physician	2004-00573	NC
2	2080P0203X	Pediatric Critical Care Medicine Physician	01073456	IN
3	2080P0214X	Pediatric Pulmonology Physician	01073456	IN
4	207LC0200X	Critical Care Medicine (Anesthesiology) Physician	01073456	IN
5	208000000X	Pediatrics Physician	2004-00573	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316152127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY L. PETERSON-CARMICHAEL M.D.

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	MEDICAL CENTER BLVD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27157-0001
Country	:	US
Telephone Number	:	336-713-4500
Fax Number	:	336-713-4501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	06/05/2026

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Directions to “ STACEY L. PETERSON-CARMICHAEL M.D.” Practice Location

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