MEDICARE: KASEY A STATUM 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	208000000X	Pediatrics Physician	21877	WV
2	208000000X	Pediatrics Physician	0101246540	VA
3	208000000X	Pediatrics Physician	227551	NY
4	208000000X	Pediatrics Physician	ME114685	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720082076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASEY A STATUM M.D.

Provider Business Mailing Address
First Line	:	4437 N CANDLEWOOD DR
Second Line	:
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-8907
Country	:	US
Telephone Number	:	301-254-4316
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 LAKELAND HILLS BLVD STE 1
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33805-3257
Country	:	US
Telephone Number	:	832-242-4735
Fax Number	:	239-302-1344

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	11/27/2023

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Directions to “ KASEY A STATUM M.D.” Practice Location

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