Healthcare Provider Details

I. General information

NPI: 1235373598
Provider Name (Legal Business Name): GRACIELA M RABRI-STACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 E DISCOVERY PKWY
BLOOMINGTON IN
47408-9059
US

IV. Provider business mailing address

PO BOX 719094
CHICAGO IL
60677-9318
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-9852
  • Fax: 812-353-5774
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01100281A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: