Provider Demographics
NPI:1861476798
Name:MACK, PHILIP WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:WILLIAM
Last Name:MACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 CAREW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2330
Mailing Address - Country:US
Mailing Address - Phone:413-787-2047
Mailing Address - Fax:413-787-2054
Practice Address - Street 1:516 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2330
Practice Address - Country:US
Practice Address - Phone:413-787-2047
Practice Address - Fax:413-787-2054
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050085207XP3100X
MA208323207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G32535Medicare UPIN