Provider Demographics
NPI:1154339620
Name:BERNER, STACEY HALE (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:HALE
Last Name:BERNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CROSSROADS DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5458
Mailing Address - Country:US
Mailing Address - Phone:410-484-8088
Mailing Address - Fax:410-581-9485
Practice Address - Street 1:10 CROSSROADS DR
Practice Address - Street 2:SUITE 210
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5458
Practice Address - Country:US
Practice Address - Phone:410-484-8088
Practice Address - Fax:410-581-9485
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0046117207X00000X
VA0101045738207X00000X
DEC10005022207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCW5200002OtherBLUE SHIELD
MD160631000Medicaid
MD53253404OtherBLUE SHIELD
MD160631000Medicaid
MD200018164Medicare PIN
KK05LL86Medicare PIN
MD066ZMedicare PIN