Basic Information
Provider Information | |||||||||
NPI: | 1578659082 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STACKHOUSE | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | G | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 EVES DR # A | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080533195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092679400 | ||||||||
FaxNumber: | 6092679457 | ||||||||
Practice Location | |||||||||
Address1: | 200 BOWMAN DR | ||||||||
Address2: | SUITE E-100 | ||||||||
City: | VOORHEES | ||||||||
State: | NJ | ||||||||
PostalCode: | 080439623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092679400 | ||||||||
FaxNumber: | 6092679457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 02/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0105X | MA46176 | NJ | Y |   | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | 174400000X | MA46176 | NJ | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 6569F02206 | 01 | NJ | 1ST OPTION | OTHER | BNS012 | 01 | NJ | OXFORD | OTHER | 0065218 | 01 | NJ | GHI | OTHER | 3730395B | 01 | NJ | CIGNA | OTHER | 157012 | 01 | NJ | GREAT WEST | OTHER | 0090628000 | 01 | NJ | KEYSTONE | OTHER | 2K1291 | 01 | NJ | HEALTHNET | OTHER | 4090523 | 01 | NJ | AETNA | OTHER | 1243672 | 01 | NJ | UNITED HEALTHCARE | OTHER | 0090628000 | 01 | NJ | AMERIHEALTH | OTHER |