Provider Demographics
NPI:1710918891
Name:STACK, PATRICK W (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:W
Last Name:STACK
Suffix:
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:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47732-3395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1373 E SR 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250
Practice Address - Country:US
Practice Address - Phone:812-801-0300
Practice Address - Fax:812-801-0585
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033161208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN412626POtherSIHO
4370916OtherAETNA
IN000000042211OtherANTHEM BCBS
KY1082594OtherPASSPORT KY MEDICAID
IN100148850AMedicaid
KY64759798Medicaid
KY2435578000OtherPASSPORT ADVANTAGE
IN412626POtherSIHO
4370916OtherAETNA
IN100148850AMedicaid
IN100148850AMedicaid