1457551657 NPI number — DR. STACY ANN MARIE DAVIS MD

Table of content: CHARLOTTE WADE (NPI 1336314137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457551657 NPI number — DR. STACY ANN MARIE DAVIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
STACY
Provider Middle Name:
ANN MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457551657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 BULLDOG BLVD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32901-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-727-2990
Provider Business Mailing Address Fax Number:
321-724-0455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1334 VALENTINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-676-1870
Provider Business Practice Location Address Fax Number:
321-768-2172
Provider Enumeration Date:
07/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RR0500X , with the licence number:  ME105521 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1082606 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 149KA . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "BEECHSTREET" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "COVENTRY/CCN/FIRST HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "NPPN/COALITION AMERICA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PRO11849 . This is a "QUALITY HEALTH PLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3666528 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3666528 . This is a "GREATWEST" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "IHG/HEALTHSMART" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6573631 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 581795 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "MULTIPLAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "EVOLUTIONS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9787626 . This is a "AETNA PPO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0000000 . This is a "FLORIDA DOCTORS INS/MALPRACTICE CARRIER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 59-3169815 . This is a "HUMANA CHOICE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 003136400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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