Provider Demographics
NPI:1679553135
Name:BLYTH, STACEY (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BLYTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-7000
Mailing Address - Fax:
Practice Address - Street 1:2630 WILLARD DAIRY RD STE 301
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8354
Practice Address - Country:US
Practice Address - Phone:336-884-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD8827OtherMEDCOST
NC89138H7Medicaid
NC138H7OtherBCBS
NCA19578OtherPRO-NET
NCP00222461OtherRAILROAD MEDICARE
NC2478977OtherUNITED HEALTHCARE
NC1366706OtherCIGNA
NC2478977OtherUNITED HEALTHCARE
NCI22097Medicare UPIN