Provider Demographics
NPI:1578610259
Name:MACK, CORI (PT)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 W NEWPORT AVE APT 3E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1124
Mailing Address - Country:US
Mailing Address - Phone:773-750-4560
Mailing Address - Fax:312-527-9202
Practice Address - Street 1:227 E ONTARIO ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3385
Practice Address - Country:US
Practice Address - Phone:773-417-6689
Practice Address - Fax:312-527-9202
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00082059OtherRAILROAD MEDICARE
ILK02192Medicare PIN