Provider Demographics
NPI:1871709964
Name:BANERJEE, STACY SWATI (MD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:SWATI
Last Name:BANERJEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639295 DEPT 93394
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9295
Mailing Address - Country:US
Mailing Address - Phone:248-266-4200
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:16600 W SPRAGUE RD STE 120
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-6300
Practice Address - Country:US
Practice Address - Phone:440-826-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35126030207R00000X
MI4301099490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0132113Medicaid
OH0132113Medicaid