Provider Demographics
NPI:1245269018
Name:GARRETT-RAY, STACY
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:GARRETT-RAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 ELKRIDGE LANDING RD
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM
Mailing Address - State:MD
Mailing Address - Zip Code:21090-2917
Mailing Address - Country:US
Mailing Address - Phone:443-462-5010
Mailing Address - Fax:410-684-2031
Practice Address - Street 1:4538 EDMONDSON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1506
Practice Address - Country:US
Practice Address - Phone:410-328-2273
Practice Address - Fax:410-362-1748
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0059648207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000951200Medicaid
MD000951200Medicaid
MDJ455Medicare PIN