Basic Information
| Provider Information | |||||||||
| NPI: | 1134111461 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1560 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056478366 | ||||||||
| FaxNumber: | 5056478381 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 AVENIDA DE MESILLA | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055253535 | ||||||||
| FaxNumber: | 5055270217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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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 | 207X00000X | 78268 | NM | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 26210 | 01 | NM | PRESBYTERIAN | OTHER | 16010 | 01 | NM | HMO | OTHER | 2666 | 01 | NM | BC BS | OTHER | 0761430001 | 01 | NM | DMERC | OTHER | 39445593 | 01 | NM | CHAMPUS | OTHER | 88005C005 | 01 | NM | TRICARE | OTHER |