Provider Demographics
NPI:1780672071
Name:EADIE, EDWARD BLEASE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:BLEASE
Last Name:EADIE
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1134 N ROAD ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3365
Mailing Address - Country:US
Mailing Address - Phone:252-338-3600
Mailing Address - Fax:252-338-8673
Practice Address - Street 1:1134 N ROAD ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3365
Practice Address - Country:US
Practice Address - Phone:252-338-3600
Practice Address - Fax:252-338-8673
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2016-06-30
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Provider Licenses
StateLicense IDTaxonomies
NC18943208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC29670OtherBLUE CROSS BLUE SHIELD
NC1780672071Medicaid
NC23290OtherMEDCOST
SCNC2727Medicaid
NC8929670Medicaid
NC206066HMedicare ID - Type Unspecified
NC1780672071Medicaid
SCNC2727Medicaid