Provider Demographics
NPI:1306893631
Name:STACK, STEVEN JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOSEPH
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:PO BOX 633815
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 N EAGLE CREEK DR
Practice Address - Street 2:ST. JOSEPH HOSPITAL EAST
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1805
Practice Address - Country:US
Practice Address - Phone:859-967-5649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076970S207P00000X
TN34619207P00000X
KY39966207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000492119OtherBCBS
TN4007244OtherBCBS
KY64131204Medicaid
TN3863430Medicaid
MS00124499Medicaid
AR16108601Medicaid
KYP00347535OtherRAILROAD MEDICARE
KY0975579Medicare PIN
KYP00347535OtherRAILROAD MEDICARE
KY000000492119OtherBCBS
TNH08983Medicare UPIN
TN3863430Medicaid
TN3863430Medicare PIN