Provider Demographics
NPI:1851410617
Name:MACK, TERRI LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRI
Middle Name:LYNNE
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6858 PLAINVIEW ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-1056
Mailing Address - Country:US
Mailing Address - Phone:734-485-8055
Mailing Address - Fax:
Practice Address - Street 1:400 MACK AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2136
Practice Address - Country:US
Practice Address - Phone:313-578-5031
Practice Address - Fax:313-578-6391
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301081963207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine