1548256977 NPI number — DR. FREDERICK RICHARD STACK MD

Table of content: ROSA MARIA BROOKS (NPI 1619424306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548256977 NPI number — DR. FREDERICK RICHARD STACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACK
Provider First Name:
FREDERICK
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1548256977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6909 EAST RAY ROAD #15-114
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-421-1122
Provider Business Mailing Address Fax Number:
520-421-0751

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51101-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-279-2010
Provider Business Practice Location Address Fax Number:
712-279-2034
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  91977 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: MD-46368 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: 24459 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 436693002 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0866740 . This is a "BLUE CROSS BLUEE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 110208816 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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