Provider Demographics
NPI:1932146685
Name:STACK, MICHAEL ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANDREW
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 1:121 N PINE RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1039
Mailing Address - Country:US
Mailing Address - Phone:989-875-5111
Mailing Address - Fax:989-875-5023
Practice Address - Street 1:121 N PINE RIVER ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1039
Practice Address - Country:US
Practice Address - Phone:989-875-5111
Practice Address - Fax:989-875-5023
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1008870OtherMCLAREN
MI0985726OtherHEALTHPLUS COMMERCIAL
MI4424316Medicaid
MI4424316OtherMOLINA
MI1005781OtherMCLAREN
MI200000005888OtherPHP COMMERCIAL
MI0802900531OtherBCBSM
MI0802911901OtherBCBSM
MI1008870OtherMCLAREN
MI080189744Medicare PIN
MI0802911901OtherBCBSM
MIG53712Medicare UPIN
MI233971Medicare Oscar/Certification