Provider Demographics
NPI:1588696314
Name:STACK, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
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:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47732-3395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1373 E SR 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250
Practice Address - Country:US
Practice Address - Phone:812-801-0300
Practice Address - Fax:812-801-0585
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN410015POtherSIHO
IN000000042214OtherANTHEM BCBS
IN100148860AMedicaid
KY1082593OtherPASSPORT KY MEDICAID
4370872OtherAETNA
KY64759780Medicaid
4370872OtherAETNA
KY1082593OtherPASSPORT KY MEDICAID
C24961Medicare UPIN
C24961Medicare UPIN