Healthcare Provider Details

I. General information

NPI: 1750524757
Provider Name (Legal Business Name): STEPHEN ANDREW STACHE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 OLD LANCASTER RD STE 100
BRYN MAWR PA
19010-3234
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 267-339-3558
  • Fax: 267-339-3763
Mailing address:
  • Phone: 800-321-9999
  • Fax: 267-479-1321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA09357400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number307130
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD443941
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: