Provider Demographics
NPI:1053406694
Name:YOUNG, STACI R (MD)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4804 S STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1904
Mailing Address - Country:US
Mailing Address - Phone:618-288-9305
Mailing Address - Fax:618-288-9308
Practice Address - Street 1:4804 S STATE ROUTE 159
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-1904
Practice Address - Country:US
Practice Address - Phone:618-288-9305
Practice Address - Fax:618-288-9308
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005020858208000000X
IL036113846208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06500123Medicaid