Basic Information
| Provider Information | |||||||||
| NPI: | 1003912353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAIT | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D., F.A.C.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11016 | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729171016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852555 | ||||||||
| FaxNumber: | 4797853555 | ||||||||
| Practice Location | |||||||||
| Address1: | 2910 JENNY LIND | ||||||||
| Address2: | BLDG #12 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729016735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797852555 | ||||||||
| FaxNumber: | 4797853555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 12/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N6996 | AR | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100199400A | 05 | OK | MEDICAID | 112530001 | 05 | AR | MEDICAID |