Healthcare Provider Details

I. General information

NPI: 1013902741
Provider Name (Legal Business Name): NICOLE STACK BROERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE MARIE STACK MD

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 ELMA G MILES PKWY
HINESVILLE GA
31313-4000
US

IV. Provider business mailing address

PO BOX 919
HINESVILLE GA
31310-0919
US

V. Phone/Fax

Practice location:
  • Phone: 912-369-9400
  • Fax: 912-877-9438
Mailing address:
  • Phone: 912-369-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number47265
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: