MEDICARE: STACEY BLYTH 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	207Q00000X	Family Medicine Physician	200401473	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00222461	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D8827	OTHER	NC	MEDCOST
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	138H7	OTHER	NC	BCBS
4	A19578	OTHER	NC	PRO-NET
6	2478977	OTHER	NC	UNITED HEALTHCARE
7	1366706	OTHER	NC	CIGNA

General Provider Information

NPI Number	:	1679553135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY BLYTH M.D.

Provider Business Mailing Address
First Line	:	1200 N ELM ST
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27401-1004
Country	:	US
Telephone Number	:	336-832-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2630 WILLARD DAIRY RD STE 301
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-8354
Country	:	US
Telephone Number	:	336-884-3800
Fax Number	:

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	08/11/2021

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Directions to “ STACEY BLYTH M.D.” Practice Location

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