Provider Demographics
NPI:1174530976
Name:BLUM, STACY D (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:BLUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:D
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1301 GRUNDMAN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEBRASKA CITY
Mailing Address - State:NE
Mailing Address - Zip Code:68410-3320
Mailing Address - Country:US
Mailing Address - Phone:402-873-4242
Mailing Address - Fax:
Practice Address - Street 1:1301 GRUNDMAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEBRASKA CITY
Practice Address - State:NE
Practice Address - Zip Code:68410-3320
Practice Address - Country:US
Practice Address - Phone:402-873-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22314207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025440000Medicaid
NE01-06552OtherUHC
NE234550OtherMIDLAND'S CHOICE
NE10025323000Medicaid
SD7717070Medicaid
IA8215335Medicaid
NE00800OtherBCBS
SD7717070Medicaid
NE01-06552OtherUHC
IA8215335Medicaid
NEP00308659Medicare PIN