Provider Demographics
NPI:1033344049
Name:STACK, KELSEY MARIE (DO)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:STACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:NY
Mailing Address - Zip Code:13084-9529
Mailing Address - Country:US
Mailing Address - Phone:315-677-8081
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2342
Practice Address - Country:US
Practice Address - Phone:315-464-5136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY262832207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03428026Medicaid
NYJ400073096Medicare PIN