Healthcare Provider Details

I. General information

NPI: 1376580175
Provider Name (Legal Business Name): MICHAEL STACK MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N PINE RIVER ST
ITHACA MI
48847-1039
US

IV. Provider business mailing address

121 N PINE RIVER ST
ITHACA MI
48847-1039
US

V. Phone/Fax

Practice location:
  • Phone: 989-875-5111
  • Fax: 989-875-5023
Mailing address:
  • Phone: 989-875-5111
  • Fax: 989-875-5023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number4301064712
License Number StateMI

VIII. Authorized Official

Name: DR. MICHAEL ANDREW STACK
Title or Position: OWNER
Credential: MD
Phone: 989-875-5111