Provider Demographics
NPI:1083976807
Name:STACK, CONOR MCCOLGAN (MD)
Entity Type:Individual
Prefix:MR
First Name:CONOR
Middle Name:MCCOLGAN
Last Name:STACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5400
Mailing Address - Country:US
Mailing Address - Phone:617-667-7000
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252843207R00000X
MA266559207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine