Provider Demographics
NPI:1457445892
Name:MACK, TERRANCE R (MD)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:R
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:HETTINGER
Mailing Address - State:ND
Mailing Address - Zip Code:58639-7533
Mailing Address - Country:US
Mailing Address - Phone:701-567-6130
Mailing Address - Fax:
Practice Address - Street 1:1000 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:HETTINGER
Practice Address - State:ND
Practice Address - Zip Code:58639
Practice Address - Country:US
Practice Address - Phone:701-567-4561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3393207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0553685Medicaid
10777OtherND BLUE CROSS
27025OtherSIOUX VALLEY
4999831OtherSD WELLMARK
123993OtherWORKERS COMP
NE45034068812Medicaid
SD7776040Medicaid
ND12565Medicaid
123993OtherWORKERS COMP
27025OtherSIOUX VALLEY
D26103Medicare UPIN
80035630Medicare ID - Type UnspecifiedTRAVELERS MEDICARE