Basic Information
| Provider Information | |||||||||
| NPI: | 1245269018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRETT-RAY | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARRETT | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 920 ELKRIDGE LANDING RD | ||||||||
| Address2: | |||||||||
| City: | LINTHICUM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210902917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434625010 | ||||||||
| FaxNumber: | 4106842031 | ||||||||
| Practice Location | |||||||||
| Address1: | 4538 EDMONDSON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212291506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103282273 | ||||||||
| FaxNumber: | 4103621748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | D0059648 | MD | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | D0059648 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000951200 | 05 | MD | MEDICAID |