Basic Information
| Provider Information | |||||||||
| NPI: | 1336436435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 N 8TH ST | ||||||||
| Address2: | PO BOX 19662 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627011041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175450253 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N 8TH ST | ||||||||
| Address2: | PAV 5B | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627011041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175458000 | ||||||||
| FaxNumber: | 2175450253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2011 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 036-142803 | IL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | 036-142803 | IL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
No ID Information.