Provider Demographics
NPI:1114946035
Name:MACK, KARIN F (MD)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:F
Last Name:MACK
Suffix:
Gender:F
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:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-0588
Mailing Address - Country:US
Mailing Address - Phone:802-442-5491
Mailing Address - Fax:802-442-4910
Practice Address - Street 1:100 LEDGEHILL RD
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2273
Practice Address - Country:US
Practice Address - Phone:802-442-5491
Practice Address - Fax:802-442-4910
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00090902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT126-1087OtherBLUE CROSS
970368OtherMVP
2018556OtherCIGNA
VT0VN1125Medicaid
10010392OtherCDPHP
VT126-1087OtherBLUE CROSS
VT0VN1125Medicaid