Basic Information
| Provider Information | |||||||||
| NPI: | 1760590525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STACK | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | THE WANAMAKER BLDG. 9TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259538 | ||||||||
| FaxNumber: | 2674259552 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902730 | ||||||||
| FaxNumber: | 2155904875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD449411 | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 102873853-0001 | 05 | PA | MEDICAID | 9780246 | 05 | MA | MEDICAID |