MEDICARE: ROBERT KEVIN STACK M.D.

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	174400000X	Specialist	26989	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982795886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT KEVIN STACK M.D.

Provider Business Mailing Address
First Line	:	1928 RANDOLPH RD STE 308
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1105
Country	:	US
Telephone Number	:	704-333-1363
Fax Number	:	704-333-6617

Provider Business Practice Location Address
First Line	:	1928 RANDOLPH RD STE 308
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1105
Country	:	US
Telephone Number	:	704-333-1363
Fax Number	:	704-333-6617

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

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/21/2022

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