Provider Demographics
NPI:1619305661
Name:EDWARD C MACK M.D.
Entity Type:Organization
Organization Name:EDWARD C MACK M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-241-0103
Mailing Address - Street 1:2855 CANDLER RD
Mailing Address - Street 2:SUITE 06
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1415
Mailing Address - Country:US
Mailing Address - Phone:404-241-0103
Mailing Address - Fax:404-241-0069
Practice Address - Street 1:2855 CANDLER RD
Practice Address - Street 2:SUITE 06
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1415
Practice Address - Country:US
Practice Address - Phone:404-241-0103
Practice Address - Fax:404-241-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000203002DMedicaid
GA000203002DMedicaid