Provider Demographics
NPI:1922202225
Name:MACK, PETER BOWMAN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:BOWMAN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-0588
Mailing Address - Fax:704-384-0580
Practice Address - Street 1:6324 FAIRVIEW RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3271
Practice Address - Country:US
Practice Address - Phone:704-384-0588
Practice Address - Fax:704-384-0580
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200801862207Q00000X
NC140928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2008-01862OtherLICENSE
NC5915838Medicaid
NC2076505Medicare PIN