Provider Demographics
NPI:1700853249
Name:EADIE, STACEY LAURINE (DO)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LAURINE
Last Name:EADIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15444
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21220-0444
Mailing Address - Country:US
Mailing Address - Phone:410-285-5437
Mailing Address - Fax:410-285-7333
Practice Address - Street 1:1105 N POINT BLVD
Practice Address - Street 2:SUITE 306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3419
Practice Address - Country:US
Practice Address - Phone:410-285-5437
Practice Address - Fax:410-285-7333
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0061035208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD001285800OtherMEDICAL ASSISTANCE