Healthcare Provider Details

I. General information

NPI: 1144532730
Provider Name (Legal Business Name): STACEY MARDIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E RIVER ST DEPARTMENT OF EMERGENCY MEDICINE
ELYRIA OH
44035-5902
US

IV. Provider business mailing address

630 E RIVER ST DEPARTMENT OF EMERGENCY MEDICINE
ELYRIA OH
44035-5902
US

V. Phone/Fax

Practice location:
  • Phone: 440-329-7450
  • Fax:
Mailing address:
  • Phone: 440-329-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.121170
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.121170
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: