Provider Demographics
NPI:1902916927
Name:STACHECKI, GEORGE P (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:P
Last Name:STACHECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 STATE HIGHWAY K
Mailing Address - Street 2:STE 100
Mailing Address - City:O'FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368
Mailing Address - Country:US
Mailing Address - Phone:636-240-5454
Mailing Address - Fax:
Practice Address - Street 1:2630 STATE HIGHWAY K
Practice Address - Street 2:STE 100
Practice Address - City:O'FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368
Practice Address - Country:US
Practice Address - Phone:636-240-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003015153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208826107Medicaid
A07795Medicare UPIN
MO208826107Medicaid