Basic Information
| Provider Information | |||||||||
| NPI: | 1376845073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MC DOWELL | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 MEMORIAL DR STE 312 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746475200 | ||||||||
| FaxNumber: | 5746475210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2010 | ||||||||
| LastUpdateDate: | 04/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | 71003872A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000000769085 | 01 | IN | BCBS BMG VASCULAR INTERVENTIONAL RAD | OTHER | 201006430 | 05 | IN | MEDICAID | P01146029 | 01 | IN | RR MEDICARE | OTHER |