Provider Demographics
NPI:1447264932
Name:STACK, CYNTHIA VERONICA (MD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:VERONICA
Last Name:STACK
Suffix:
Gender:F
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:CHILDRENS MEMORIAL HOSPITAL #52
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-880-4352
Mailing Address - Fax:773-880-3896
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:CHILDRENS MEMORIAL HOSPITAL #52
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-880-4352
Practice Address - Fax:773-880-3896
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL0360513102084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036051310Medicaid
ILP08799Medicare ID - Type Unspecified
IL036051310Medicaid