=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700805090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACIE B PEDDY M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3100 SW 62ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-3009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-666-6511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3100 SW 62ND AVE
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-3009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-666-6511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number | MD426570
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD426570
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number | MD426570
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number | D92544
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number | ME167338
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------