Provider Demographics
NPI:1437165164
Name:STACK, BRENDAN CURRAN JR (MD)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:CURRAN
Last Name:STACK
Suffix:JR
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 1:21001 LAKE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72135-8017
Mailing Address - Country:US
Mailing Address - Phone:501-868-7299
Mailing Address - Fax:
Practice Address - Street 1:720 N BOND ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4952
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4564207Y00000X, 207YS0123X
ARE-4564207YX0007X
IL036-151806207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ART2005-275OtherTRICARE
AR0507002300OtherQUALCHOICE
AR5N281OtherBCBS
5N2817666OtherADDITIONAL MEDICARE
ARE4564OtherMEDICAL LICENSE
AR158045001Medicaid
ARE4564OtherMEDICAL LICENSE