Provider Demographics
NPI:1871506915
Name:STACKHOUSE, CAROLINE M (MD)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:M
Last Name:STACKHOUSE
Suffix:
Gender:F
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 635232
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-2082
Practice Address - Country:US
Practice Address - Phone:706-629-2895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042898207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000744235KMedicaid
GAP00333881OtherRAILROAD MEDICARE
GAP00333881OtherRAILROAD MEDICARE
GAG09153Medicare UPIN