Healthcare Provider Details

I. General information

NPI: 1780672071
Provider Name (Legal Business Name): EDWARD BLEASE EADIE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 N ROAD ST SUITE 5
ELIZABETH CITY NC
27909-3365
US

IV. Provider business mailing address

1134 N ROAD ST SUITE 5
ELIZABETH CITY NC
27909-3365
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-3600
  • Fax: 252-338-8673
Mailing address:
  • Phone: 252-338-3600
  • Fax: 252-338-8673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number18943
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: