Provider Demographics
NPI:1417987470
Name:MACK, THOMAS VAL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:VAL
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3003 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-4110
Mailing Address - Country:US
Mailing Address - Phone:715-735-1737
Mailing Address - Fax:715-735-1794
Practice Address - Street 1:4061 OLD PESHTIGO RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3887
Practice Address - Country:US
Practice Address - Phone:715-732-8090
Practice Address - Fax:715-732-8015
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21285-20208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01529036OtherMEDICARE RAILROAD
WI30126200Medicaid
MI104160568Medicaid
WI930079990OtherMEDICARE RAILROAD
B54733Medicare UPIN
WI30126200Medicaid