Provider Demographics
NPI:1215223490
Name:STACK, MELINDA ELLEN (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:ELLEN
Last Name:STACK
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 1:5140 N CALIFORNIA AVE STE 560
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2577
Mailing Address - Country:US
Mailing Address - Phone:847-570-1700
Mailing Address - Fax:847-982-1098
Practice Address - Street 1:5140 N CALIFORNIA AVE STE 560
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2577
Practice Address - Country:US
Practice Address - Phone:847-570-1700
Practice Address - Fax:847-982-1098
Is Sole Proprietor?:No
Enumeration Date:2011-06-25
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036135948208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery