1578659082 NPI number — DR. THOMAS G STACKHOUSE MD

Table of content: DR. THOMAS G STACKHOUSE MD (NPI 1578659082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578659082 NPI number — DR. THOMAS G STACKHOUSE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACKHOUSE
Provider First Name:
THOMAS
Provider Middle Name:
G
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:
1578659082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 EVES DR # A
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-3195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-267-9400
Provider Business Mailing Address Fax Number:
609-267-9457

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 BOWMAN DR
Provider Second Line Business Practice Location Address:
SUITE E-100
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-9623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-267-9400
Provider Business Practice Location Address Fax Number:
609-267-9457
Provider Enumeration Date:
10/04/2006

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: 2086S0105X , with the licence number:  MA46176 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: MA46176 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6569F02206 . This is a "1ST OPTION" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: BNS012 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0065218 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3730395B . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 157012 . This is a "GREAT WEST" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0090628000 . This is a "KEYSTONE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2K1291 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 4090523 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1243672 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0090628000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com