Provider Demographics
NPI:1982795886
Name:STACK, ROBERT KEVIN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KEVIN
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 1:1928 RANDOLPH RD STE 308
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1105
Mailing Address - Country:US
Mailing Address - Phone:704-333-1363
Mailing Address - Fax:704-333-6617
Practice Address - Street 1:1928 RANDOLPH RD STE 308
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1105
Practice Address - Country:US
Practice Address - Phone:704-333-1363
Practice Address - Fax:704-333-6617
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26989174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8979122Medicaid
D42353Medicare UPIN
NC8979122Medicaid