Basic Information
| Provider Information | |||||||||
| NPI: | 1720039522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREGORY | ||||||||
| FirstName: | STACY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650865 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CITYWEST BLVD | ||||||||
| Address2: | STE. 300 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770422300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7134584229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 02/27/2017 | ||||||||
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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 | 207L00000X | 39354 | KY | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 096694 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | P9358 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 3145019 | 05 | OH | MEDICAID | 50025230 | 01 | PASSPORT | OTHER | 000000635467 | 01 | IN | ANTHEM | OTHER | 107356 | 01 | IN | SIHO | OTHER | P01444554 | 01 | TX | RR MEDICARE | OTHER | 129703800 | 01 | US DEPT OF LABOR | OTHER | 339125201 | 05 | TX | MEDICAID | GR4317491 | 01 | MEDICARE | OTHER | 3730868000 | 01 | PASSPORT ADVANTAGE | OTHER | 8ER269 | 01 | TX | BCBS | OTHER |