Provider Demographics
NPI:1053318899
Name:NOBLE-SHRIVER, STACIE J (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:J
Last Name:NOBLE-SHRIVER
Suffix:
Gender:F
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:ONE HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557
Mailing Address - Country:US
Mailing Address - Phone:508-693-0410
Mailing Address - Fax:
Practice Address - Street 1:ONE HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:508-693-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202501207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0191612Medicaid
G41817Medicare UPIN
MAA31042Medicare ID - Type Unspecified