MEDICARE: DR. BRIAN KHRISTOPHER STACKHOUSE MD

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1871234989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN KHRISTOPHER STACKHOUSE MD

Provider Business Mailing Address
First Line	:	376 SEGUINE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-3942
Country	:	US
Telephone Number	:	718-226-5976
Fax Number	:	718-226-2789

Provider Business Practice Location Address
First Line	:	376 SEGUINE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10309-3942
Country	:	US
Telephone Number	:	718-226-5976
Fax Number	:	718-226-2789

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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