Healthcare Provider Details

I. General information

NPI: 1700853249
Provider Name (Legal Business Name): STACEY LAURINE EADIE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2006
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:
Title or Position:
Credential:
Phone: