Provider Demographics
NPI:1255351201
Name:EDDY, STEPHEN DERRICK (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DERRICK
Last Name:EDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MEDICAL PARK
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6391
Mailing Address - Country:US
Mailing Address - Phone:304-243-8630
Mailing Address - Fax:304-243-8575
Practice Address - Street 1:30 MEDICAL PARK
Practice Address - Street 2:SUITE 201
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6391
Practice Address - Country:US
Practice Address - Phone:304-243-8630
Practice Address - Fax:304-243-8575
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084571207RS0010X
PAPA MD429317207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00469047OtherRR MEDICARE
PA0018294730001Medicaid
OH2679632Medicaid
WV3810006366Medicaid
OHP00428195OtherMEDICARE RAILROAD
PA106877PK7Medicare PIN
PAP00469047OtherRR MEDICARE
PA0018294730001Medicaid
OH4189241Medicare PIN