Provider Demographics
NPI:1629071170
Name:SACK, MARSHALL BARNETT (DO)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:BARNETT
Last Name:SACK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39500 W 10 MILE RD
Mailing Address - Street 2:STE. 100
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2947
Mailing Address - Country:US
Mailing Address - Phone:248-476-0035
Mailing Address - Fax:248-476-2418
Practice Address - Street 1:39500 W 10 MILE RD
Practice Address - Street 2:STE. 100
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2947
Practice Address - Country:US
Practice Address - Phone:248-476-0035
Practice Address - Fax:248-476-2418
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDR630349OtherMCARE
MI0156304195OtherBCBSM
MS007596OtherBCBSM OTHER IDENTIFIER
MIA76040OtherHAP
MI1411744Medicaid
MI0800028260OtherRAILROAD MEDICARE
MI0156304195OtherBCBSM
A76040Medicare UPIN
MI1411744Medicaid