MEDICARE: DR. STACEY BLAZINA D.O.

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	208000000X	Pediatrics Physician	87900	SC

General Provider Information

NPI Number	:	1679730915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACEY BLAZINA D.O.

Provider Business Mailing Address
First Line	:	1903 BETHEL RD
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-5729
Country	:	US
Telephone Number	:	570-367-9236
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 VERDAE BLVD STE 200
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-4021
Country	:	US
Telephone Number	:	864-272-0388
Fax Number	:

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

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	09/05/2023

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