Healthcare Provider Details

I. General information

NPI: 1700311818
Provider Name (Legal Business Name): STACY GREETER, MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9030 58TH DR E SUITE 101A, ROOM A
BRADENTON FL
34202-6108
US

IV. Provider business mailing address

9030 58TH DR E SUITE 101A, ROOM A
BRADENTON FL
34202-6108
US

V. Phone/Fax

Practice location:
  • Phone: 941-413-0834
  • Fax: 941-761-5547
Mailing address:
  • Phone: 941-413-0834
  • Fax: 941-761-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberME 128423
License Number StateFL

VIII. Authorized Official

Name: DR. STACY LYNN GREETER
Title or Position: PHYSICIAN
Credential: MD
Phone: 904-228-0777