Individual
STACI R YOUNG
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4804 S STATE ROUTE 159, GLEN CARBON, IL 62034-1904
(618) 288-9305
(618) 288-9308
Mailing address
4804 S STATE ROUTE 159, GLEN CARBON, IL 62034-1904
(618) 288-9305
(618) 288-9308
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
036113846
IL
208000000X
Pediatrics Physician
2005020858
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
06500123
—
IL
Enumeration date
10/03/2006
Last updated
06/29/2020
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