MEDICARE: DR. STACEY LANA BAUGAARD O.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	152W00000X	Optometrist	OEG002515	PA

General Provider Information

NPI Number	:	1508154881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY LANA BAUGAARD O.D

Provider Business Mailing Address
First Line	:	2001 HAMILTON ST PH 107
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-4201
Country	:	US
Telephone Number	:	267-615-1502
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 W BIG BEAVER RD
Second Line	:	SUITE 655
City	:	TROY
State	:	MI
Zip	:	48084-5206
Country	:	US
Telephone Number	:	419-874-0393
Fax Number	:

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

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	07/20/2011

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