Provider Demographics
NPI:1245329101
Name:RUFFIN, MACK T IV (MD)
Entity type:Individual
Prefix:
First Name:MACK
Middle Name:T
Last Name:RUFFIN
Suffix:IV
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 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:140 OLD WILLOW MILL RD
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-1816
Practice Address - Country:US
Practice Address - Phone:717-766-4635
Practice Address - Fax:717-766-4818
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055570207Q00000X
PAMD459216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA534246OtherMEDICARE PTAN
PA1031816190001Medicaid
MI2623517Medicaid
MI0H17630016Medicare ID - Type Unspecified
MI2623517Medicaid