Basic Information
| Provider Information | |||||||||
| NPI: | 1659389039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STACY | ||||||||
| FirstName: | DONNIE | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471303769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122823899 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 S DUPONT SQ | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027210116 | ||||||||
| FaxNumber: | 8122856010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 036-110971 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | K008661 | 05 | KY | MEDICAID |