Individual
SUSAN M STACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
01033162
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000042214
ANTHEM BCBS
IN
05
—
100148860A
—
IN
01
—
1082593
PASSPORT KY MEDICAID
KY
01
—
410015P
SIHO
IN
01
—
4370872
AETNA
—
05
—
64759780
—
KY
Enumeration date
07/06/2006
Last updated
02/20/2019
Update your record
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