Provider Demographics
NPI:1871686337
Name:DACK, MARTY PHILLIP (NP)
Entity Type:Individual
Prefix:MR
First Name:MARTY
Middle Name:PHILLIP
Last Name:DACK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1703 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-2841
Mailing Address - Country:US
Mailing Address - Phone:517-913-3860
Mailing Address - Fax:517-484-6864
Practice Address - Street 1:1703 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2841
Practice Address - Country:US
Practice Address - Phone:517-913-3860
Practice Address - Fax:517-484-6864
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1057822OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI200000006547OtherPHP FAMILYCARE
MI4950304Medicaid
MI5008702500OtherBLUE CROSS BLUE SHILED
MIP00367059OtherRAILROAD MEDICARE
MI1057822OtherMCLAREN HEALTH ADVANTAGE
MI1057822OtherMCLAREN HEALTH PLAN-MEDICAID
MI7952506OtherAETNA
MIN55170013OtherMEDICARE PLUS BLUE
MI200000006547OtherPHP
MI200000006547OtherPHP
MIQ12377Medicare UPIN