Provider Demographics
NPI:1275522625
Name:MACK, JONATHAN EBERHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EBERHARD
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:185 QUEEN CITY AVE
Mailing Address - Street 2:ELLIOT ORTHOPAEDIC SURGERY SPECIALISTS
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-7100
Mailing Address - Country:US
Mailing Address - Phone:603-625-1655
Mailing Address - Fax:603-626-4686
Practice Address - Street 1:185 QUEEN CITY AVE
Practice Address - Street 2:ELLIOT ORTHOPAEDIC SURGERY SPECIALISTS
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-7100
Practice Address - Country:US
Practice Address - Phone:603-625-1655
Practice Address - Fax:603-626-4686
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ33787207XX0005X
WI50942207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34952800Medicaid
WI103772200Medicare PIN
AZI20967Medicare UPIN
WII20967Medicare UPIN