Provider Demographics
NPI: | 1265506463 |
---|---|
Name: | TAM, STACY ROBIN (DC) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | STACY |
Middle Name: | ROBIN |
Last Name: | TAM |
Suffix: | |
Gender: | F |
Credentials: | DC |
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 148 |
Mailing Address - Street 2: | |
Mailing Address - City: | MARION |
Mailing Address - State: | MA |
Mailing Address - Zip Code: | 02738-0003 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 508-748-6633 |
Mailing Address - Fax: | 508-748-6649 |
Practice Address - Street 1: | 238 WAREHAM RD |
Practice Address - Street 2: | |
Practice Address - City: | MARION |
Practice Address - State: | MA |
Practice Address - Zip Code: | 02738-1166 |
Practice Address - Country: | US |
Practice Address - Phone: | 508-748-6633 |
Practice Address - Fax: | 508-748-6649 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-20 |
Last Update Date: | 2014-03-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MA | 3100 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MA | 7198894 | Other | AETNA |
MA | Y37172 | Other | BCBS |
MA | 1265506463 | Other | BMC HEALTHNET |
MA | 1614142 | Medicaid | |
MA | 711883 | Other | UNITED HEALTHCARE |
MA | 711883 | Other | ACN NETWORK |
MA | AA96361 | Other | HARVARD PILGRAM |
MA | 1265506463 | Other | BMC HEALTHNET |