1730105172 NPI number — STACY EDWARDS, INC

Table of content: (NPI 1730105172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730105172 NPI number — STACY EDWARDS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STACY EDWARDS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STACY L. EDWARDS, D.O.
Provider Other Organization Name Type Code:
3
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:
1730105172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1022 MAIN ST
Provider Second Line Business Mailing Address:
SUITE M
Provider Business Mailing Address City Name:
DUNEDIN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34698-5225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-733-7922
Provider Business Mailing Address Fax Number:
737-738-6205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1022 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
DUNEDIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34698-5225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-733-7922
Provider Business Practice Location Address Fax Number:
737-738-6205
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
STACY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
727-733-7922

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS7714 , 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: 20886 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0412595 . This is a "UHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1320 . This is a "BAYCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 257297 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0161979008 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 5580758 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0001713 . This is a "UHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1057441 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 123421 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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