Provider Demographics
NPI:1003912353
Name:TAIT, STACY ROBERT (MD, FACC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:ROBERT
Last Name:TAIT
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11016
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1016
Mailing Address - Country:US
Mailing Address - Phone:479-785-2555
Mailing Address - Fax:479-785-3555
Practice Address - Street 1:2910 JENNY LIND
Practice Address - Street 2:BLDG #12
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-6735
Practice Address - Country:US
Practice Address - Phone:479-785-2555
Practice Address - Fax:479-785-3555
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6996207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100199400AMedicaid
AR112530001Medicaid
AR50633Medicare ID - Type Unspecified
OK100199400AMedicaid