Provider Demographics
NPI:1205889565
Name:SACK, J GARRY (MD)
Entity type:Individual
Prefix:
First Name:J
Middle Name:GARRY
Last Name:SACK
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 1:2801 WESTHILL DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3700
Mailing Address - Country:US
Mailing Address - Phone:715-847-2021
Mailing Address - Fax:715-847-2325
Practice Address - Street 1:2801 WESTHILL DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3700
Practice Address - Country:US
Practice Address - Phone:715-847-2021
Practice Address - Fax:715-847-2325
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18475-020207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30108700Medicaid
WI30108700Medicaid