Provider Demographics
NPI:1902063407
Name:STACK, ANDREW PHILLIP (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:PHILLIP
Last Name:STACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-8180
Mailing Address - Fax:912-350-5697
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8180
Practice Address - Fax:912-350-5697
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0718862080P0203X, 207L00000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146322AMedicaid
GAP01335436OtherRAILROAD MEDICARE
GAP01335436OtherRAILROAD MEDICARE