MEDICARE: DR. STACI R EISENBERG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MD15098	RI
2	207R00000X	Internal Medicine Physician	220587	MA
3	207R00000X	Internal Medicine Physician	MD15098	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MD15098	OTHER	RI	LICENSE

General Provider Information

NPI Number	:	1033109301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACI R EISENBERG MD

Provider Business Mailing Address
First Line	:	1153 CENTRE ST
Second Line	:
City	:	JAMAICA PLAIN
State	:	MA
Zip	:	02130-3446
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1153 CENTRE ST
Second Line	:
City	:	JAMAICA PLAIN
State	:	MA
Zip	:	02130-3446
Country	:	US
Telephone Number	:	617-983-7025
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	02/07/2019

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