Provider Demographics
NPI:1376580175
Name:MICHAEL STACK MD PC
Entity Type:Organization
Organization Name:MICHAEL STACK MD PC
Other - Org Name:FAMILY MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-875-5111
Mailing Address - Street 1:121 N PINE RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1039
Mailing Address - Country:US
Mailing Address - Phone:989-875-5111
Mailing Address - Fax:989-875-5023
Practice Address - Street 1:121 N PINE RIVER ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1039
Practice Address - Country:US
Practice Address - Phone:989-875-5111
Practice Address - Fax:989-875-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X, 363LF0000X
MI4301064712261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B91071OtherBCBSM
MI233971Medicare Oscar/Certification
MI0N55970Medicare PIN