Provider Demographics
NPI:1487673232
Name:MACK, SARAH ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ROSE
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ROSE
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1523 GREENSBORO WAY
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-2907
Mailing Address - Country:US
Mailing Address - Phone:770-316-2883
Mailing Address - Fax:770-972-7332
Practice Address - Street 1:821 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2343
Practice Address - Country:US
Practice Address - Phone:478-454-3795
Practice Address - Fax:478-454-3969
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
GA039858207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00653001UMedicaid
GA93BDVRFMedicare ID - Type Unspecified
GA00653001UMedicaid