Provider Demographics
NPI:1801899885
Name:STACK, EDWARD P (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
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 1:5300 GATEWAY CTR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3930
Mailing Address - Country:US
Mailing Address - Phone:810-720-9111
Mailing Address - Fax:810-720-9119
Practice Address - Street 1:5300 GATEWAY CTR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3930
Practice Address - Country:US
Practice Address - Phone:810-720-9111
Practice Address - Fax:810-720-9119
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065179207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15474OtherSPECTERA
MI5100110OtherAETNA
MI4774225Medicaid
MIC6993OtherMCARE
MI6736673005OtherCIGNA
MI110201OtherCARE CHOICES
MI1802511821OtherBCBSM
MI4301065179OtherSTATE LICENSE NUMBER
MI000000010198OtherCAPE MEDICAID
MI028341OtherMIDWEST HEALTH
MI4604520Medicaid
MI4774225Medicaid
MI4604520Medicaid
MAP00282479Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MIN88400002Medicare ID - Type Unspecified
MI4301065179OtherSTATE LICENSE NUMBER