Provider Demographics
NPI:1073788212
Name:STACY R TAIT PA
Entity Type:Organization
Organization Name:STACY R TAIT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-771-4693
Mailing Address - Street 1:2201 WYNDEMERE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903
Mailing Address - Country:US
Mailing Address - Phone:501-771-4693
Mailing Address - Fax:501-771-4885
Practice Address - Street 1:5518 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3222
Practice Address - Country:US
Practice Address - Phone:501-771-4693
Practice Address - Fax:501-771-4885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty