Provider Demographics
NPI:1811205024
Name:PINEBROOK MEDICAL CENTER LLC,
Entity Type:Organization
Organization Name:PINEBROOK MEDICAL CENTER LLC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-808-3200
Mailing Address - Street 1:170 CHANGEBRIDGE RD BLDG A3
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-8802
Mailing Address - Country:US
Mailing Address - Phone:973-808-3200
Mailing Address - Fax:973-808-3202
Practice Address - Street 1:170 CHANGEBRIDGE ROAD
Practice Address - Street 2:SUITE A-3
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045
Practice Address - Country:US
Practice Address - Phone:973-808-3200
Practice Address - Fax:973-808-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB58292261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJST624751Medicare PIN
NJF93378Medicare UPIN