Provider Demographics
NPI:1710979067
Name:STALLMEYER, MARY JOANNE BERNADETTE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JOANNE BERNADETTE
Last Name:STALLMEYER
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6TH AVENUE & SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:WEST READING
Mailing Address - State:PA
Mailing Address - Zip Code:19611-1428
Mailing Address - Country:US
Mailing Address - Phone:610-988-8059
Mailing Address - Fax:610-988-4242
Practice Address - Street 1:6TH AVENUE & SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:WEST READING
Practice Address - State:PA
Practice Address - Zip Code:19611-1428
Practice Address - Country:US
Practice Address - Phone:610-988-8059
Practice Address - Fax:610-988-4242
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00522632085N0700X, 2085R0202X, 2085R0204X
PAMD4419792085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1883824Medicaid
PA102564535001Medicaid
MD110800000 2662043Medicaid
MD967707OtherAETNA HMO
DC3811 0020OtherCAREFIRST BCBS DC
MD5235541OtherAETNA PPO
MDKC46SHOtherCAREFIRST
MD865L181EMedicare PIN
PA215708Medicare PIN
MD5235541OtherAETNA PPO
MDG09961Medicare UPIN
LA1883824Medicaid
MD545L 784VMedicare PIN