Provider Demographics
NPI:1578659082
Name:STACKHOUSE, THOMAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:STACKHOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4 EVES DR # A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3195
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:609-267-9457
Practice Address - Street 1:200 BOWMAN DR
Practice Address - Street 2:SUITE E-100
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9623
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:609-267-9457
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA461762086S0105X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6569F02206Other1ST OPTION
NJBNS012OtherOXFORD
NJ0065218OtherGHI
NJ3730395BOtherCIGNA
NJ157012OtherGREAT WEST
NJ0090628000OtherKEYSTONE
NJ2K1291OtherHEALTHNET
NJ4090523OtherAETNA
NJ1243672OtherUNITED HEALTHCARE
NJ0090628000OtherAMERIHEALTH
NJ0090628000OtherKEYSTONE
NJ1243672OtherUNITED HEALTHCARE