Basic Information
| Provider Information | |||||||||
| NPI: | 1578530093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIERCE | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROMOSER | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 8936 SOUTHPOINTE DR | ||||||||
| Address2: | SUITE A-1 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462277507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178883838 | ||||||||
| FaxNumber: | 3178883838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 10/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05007138A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200485020 | 05 | IN | MEDICAID | 000000334938 | 01 | IN | ANTHEM ID | OTHER |