Provider Demographics
NPI:1164955746
Name:STACK, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:COYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1721 E 19TH AVE STE 520
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2718
Practice Address - Country:US
Practice Address - Phone:847-639-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005891213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery