Individual
BRENDAN CURRAN STACK JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
720 N BOND ST, SPRINGFIELD, IL 62702-4952
(217) 545-8000
Mailing address
21001 LAKE VISTA DR, ROLAND, AR 72135-8017
(501) 868-7299
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
E4564
AR
207YS0123X
Facial Plastic Surgery Physician
E4564
AR
207YX0007X
Plastic Surgery within the Head & Neck (Otolaryngology) Physician
Primary
036-151806
IL
207YX0007X
Plastic Surgery within the Head & Neck (Otolaryngology) Physician
E-4564
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0507002300
QUALCHOICE
AR
05
—
158045001
—
AR
01
—
5N281
BCBS
AR
01
—
5N2817666
ADDITIONAL MEDICARE
—
01
—
E4564
MEDICAL LICENSE
AR
01
—
T2005-275
TRICARE
AR
Enumeration date
08/01/2006
Last updated
02/19/2020
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