Nicole Stack Broerman, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

47265 Issued in GA

Practice address

462 Elma G Miles Pkwy
Hinesville, GA 31313-4000

Phone

(912) 369-9400

Fax

(912) 877-9438

NPI assigned

Sep 19, 2005

Last updated

Apr 17, 2018By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Dr. Nicole Marie Stack Former name

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: nicolebroerman@sip.allscriptsdirect.net

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Hospital Authority of Liberty County

  dba Liberty Regional Medical Center

  • Critical Access Hospital
  • Hinesville, GA
  • NPI 1326079260

  Multi-Specialty

  Medicare reassignment NPD
• Hospital Authority of Liberty County

  dba Liberty Regional Orthopaedics

  • Orthopaedic Surgery Physician
  • Hinesville, GA
  • NPI 1023443801

  Multi-Specialty

  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1127088000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1523923200000",
    "number": "1013902741",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 919",
            "city": "HINESVILLE",
            "state": "GA",
            "postal_code": "313100919",
            "telephone_number": "912-369-9400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "462 ELMA G MILES PKWY",
            "city": "HINESVILLE",
            "state": "GA",
            "postal_code": "313134000",
            "telephone_number": "912-369-9400",
            "fax_number": "912-877-9438"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROERMAN",
        "first_name": "NICOLE",
        "middle_name": "STACK",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2005-09-19",
        "last_updated": "2018-04-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "47265",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "T74835",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "STACK",
            "middle_name": "MARIE",
            "prefix": "DR.",
            "credential": "MD",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Wendy Marie Brady
• Caleb Branham
• Lauren Jean Bremer, MD
• Kimberly Brewton
• Jennifer Brinkley
• Aaliyah Tenayaa Brooks-Elensky
• Jada Brooks
• Sheniqua Ann Brooks
• Kristina Brower, FNP
• Antonius Darius Brown, PT, DPT

• Pediatrics Physician in Hinesville, GA
• Providers in Hinesville, GA by specialty
• Pediatrics Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.