1770585945 NPI number — DR. MICHAEL T STACK MD PHD

Table of content: DR. MICHAEL T STACK MD PHD (NPI 1770585945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770585945 NPI number — DR. MICHAEL T STACK MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACK
Provider First Name:
MICHAEL
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1770585945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6551 FORREST COMMONS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46227-2392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6447 S EAST ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-859-6364
Provider Business Practice Location Address Fax Number:
317-859-7537
Provider Enumeration Date:
06/01/2005

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: 1744R1102X , with the licence number:  01026374 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 01026374 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 71508 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100133510B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1265457774 . This is a "OFFICE/GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100083069 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000318888 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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