Provider Demographics
NPI:1558445577
Name:STACK, TAMMY MARIE (PT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MARIE
Last Name:STACK
Suffix:
Gender:F
Credentials:PT
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 220
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-0220
Mailing Address - Country:US
Mailing Address - Phone:708-590-6663
Mailing Address - Fax:708-469-4100
Practice Address - Street 1:15441 S 94TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3827
Practice Address - Country:US
Practice Address - Phone:708-981-3715
Practice Address - Fax:708-315-7087
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-007458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCJ4383OtherR.R. MED. GROUP #
ILP00624020OtherMEDICARE RAIL ROAD
IL1619908OtherBCBS IL GROUP NUMBER
ILCD3789OtherMEDICARE RAIL ROAD GROUP
IL650022809OtherR.R. MEDICARE PIN #
IL1623066OtherBCBS PROIVDER #
IL367885100OtherUS DEPT OF LABOR #
ILR02268Medicare PIN
ILL75352Medicare PIN
ILR02269Medicare PIN
ILP00624020OtherMEDICARE RAIL ROAD
ILCJ4383OtherR.R. MED. GROUP #
IL568080Medicare PIN
IL567700Medicare PIN
IL367885100OtherUS DEPT OF LABOR #
IL202542Medicare ID - Type UnspecifiedMEDICARE GROUP #