MEDICARE: CAMILLE N STACKHOUSE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	085.003540	IL

General Provider Information

NPI Number	:	1366674467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLE N STACKHOUSE PA

Provider Business Mailing Address
First Line	:	7271 S SOUTH SHORE DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-2893
Country	:	US
Telephone Number	:	773-314-7090
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 E GOLF RD
Second Line	:	SUITE 2133
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-5222
Country	:	US
Telephone Number	:	847-290-9122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2009
Last Update Date	:	08/23/2009

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