Provider Demographics
NPI:1376531913
Name:MACK, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4708 ALLIANCE BLVD
Mailing Address - Street 2:SUITE 700, PAVILLION I
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5340
Mailing Address - Country:US
Mailing Address - Phone:972-596-6676
Mailing Address - Fax:972-596-7078
Practice Address - Street 1:4708 ALLIANCE BLVD
Practice Address - Street 2:SUITE 700, PAVILLION I
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5340
Practice Address - Country:US
Practice Address - Phone:972-596-6676
Practice Address - Fax:972-596-7078
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-09-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXF6018208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115911305Medicaid
TXTXB113115Medicare PIN
TXP01058482Medicare PIN
C18652Medicare UPIN