=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578659082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS G STACKHOUSE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 02/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BOWMAN DR SUITE E-100
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-9623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-267-9400
-----------------------------------------------------
Fax | 609-267-9457
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 EVES DR # A SUITE 100
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-3195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-267-9400
-----------------------------------------------------
Fax | 609-267-9457
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0105X
-----------------------------------------------------
Taxonomy Name | Surgery of the Hand (Surgery) Physician
-----------------------------------------------------
License Number | MA46176
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA46176
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------