Healthcare Provider Details

I. General information

NPI: 1336453463
Provider Name (Legal Business Name): PEDS IN A POD PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2010
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 N POINT BLVD SUITE 306
BALTIMORE MD
21224-3419
US

IV. Provider business mailing address

PO BOX 15444
BALTIMORE MD
21220-0444
US

V. Phone/Fax

Practice location:
  • Phone: 410-285-5437
  • Fax: 410-285-7333
Mailing address:
  • Phone: 410-285-5437
  • Fax: 410-285-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberH0061035
License Number StateMD

VIII. Authorized Official

Name: STACEY L. EADIE
Title or Position: OWNER
Credential: D.O.
Phone: 443-421-6966