Basic Information
| Provider Information | |||||||||
| NPI: | 1750338356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEREDITH | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ER DEPT | ||||||||
| Address2: | 2450 ASHBY AVE | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102042500 | ||||||||
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| Practice Location | |||||||||
| Address1: | ER DEPT | ||||||||
| Address2: | 2450 ASHBY AVE | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102042500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | A88699 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A886990 | 05 | CA | MEDICAID |