Basic Information
| Provider Information | |||||||||
| NPI: | 1477715571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STACK | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
| Address2: | EMERGENCY MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037560001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036507254 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
| Address2: | EMERGENCY MEDICINE | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037560001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036507254 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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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 | 207P00000X | 239371 | MA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 19481 | NH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3116463 | 05 | NH | MEDICAID | 1035907 | 05 | VT | MEDICAID |