Provider Demographics
NPI:1053303453
Name:EADLINE, STEPHEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:EADLINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 BURRSTONE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0001
Mailing Address - Country:US
Mailing Address - Phone:315-798-1551
Mailing Address - Fax:315-798-1556
Practice Address - Street 1:1729 BURRSTONE ROAD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-0001
Practice Address - Country:US
Practice Address - Phone:315-798-1551
Practice Address - Fax:315-798-1556
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170183208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01015135Medicaid
NY01015136Medicaid
NY01015136Medicaid
RA0905Medicare PIN
NYE15656Medicare UPIN