Basic Information
| Provider Information | |||||||||
| NPI: | 1841420494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAL | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | GUREVITZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100275 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522650680 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148202251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2009 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | ME120323 | FL | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZC0006X | P2254 | TX | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 012660400 | 05 | FL | MEDICAID |