Provider Demographics
NPI:1962645226
Name:MACK OCCUPATIONAL HEALTH SERVICES SC
Entity Type:Organization
Organization Name:MACK OCCUPATIONAL HEALTH SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-424-4089
Mailing Address - Street 1:2643 LIBAL STREET
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-435-1604
Mailing Address - Fax:920-435-1670
Practice Address - Street 1:N528 FAIRLAND ISLAND
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858
Practice Address - Country:US
Practice Address - Phone:906-424-4089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty