Provider Demographics
NPI:1700311818
Name:STACY GREETER, MD, PLLC
Entity type:Organization
Organization Name:STACY GREETER, MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GREETER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-228-0777
Mailing Address - Street 1:9030 58TH DR E
Mailing Address - Street 2:SUITE 101A, ROOM A
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-6108
Mailing Address - Country:US
Mailing Address - Phone:941-413-0834
Mailing Address - Fax:941-761-5547
Practice Address - Street 1:9030 58TH DR E
Practice Address - Street 2:SUITE 101A, ROOM A
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34202-6108
Practice Address - Country:US
Practice Address - Phone:941-413-0834
Practice Address - Fax:941-761-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 128423261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1215257845OtherINDIVIDUAL NPI