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General NPI Number Information
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NPI Number | 1437165164
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Entity Type | Individual
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Provider Name | BRENDAN CURRAN STACK JR. MD
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Gender | Male
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 02/19/2020
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Provider Practice Location Address
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Address Line | 720 N BOND ST
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City | SPRINGFIELD
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State | IL
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Zip | 62702-4952
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Country | US
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Telephone | 217-545-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 21001 LAKE VISTA DR
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City | ROLAND
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State | AR
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Zip | 72135-8017
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Country | US
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Telephone | 501-868-7299
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | E4564
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 207YS0123X
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Taxonomy Name | Facial Plastic Surgery Physician
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License Number | E4564
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | E-4564
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License Number State | AR
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Taxonomy #4
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | 036-151806
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License Number State | IL
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