Basic Information
| Provider Information | |||||||||
| NPI: | 1093715047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STIBICH | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | STEFAN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3633 CENTRAL AVE | ||||||||
| Address2: | STE N | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016236100 | ||||||||
| FaxNumber: | 5016236187 | ||||||||
| Practice Location | |||||||||
| Address1: | 3633 CENTRAL AVE | ||||||||
| Address2: | STE N | ||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719136404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016236100 | ||||||||
| FaxNumber: | 5016236187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 09/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0101X | E2886 | AR | N | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | E2886 | AR | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 143844001 | 05 | AR | MEDICAID | E2886 | 01 | AR | STATE LICENSE | OTHER | 18885000000 | 01 | AR | QUALCHOICE | OTHER | 7237284 | 01 | AETNA | OTHER |