Provider Demographics
NPI:1245338110
Name:MACK, EDWARD C (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
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:P.O. BOX 370569
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30037
Mailing Address - Country:US
Mailing Address - Phone:678-492-5985
Mailing Address - Fax:404-420-0117
Practice Address - Street 1:315 BOULEVARD NE
Practice Address - Street 2:SUITE 444
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1200
Practice Address - Country:US
Practice Address - Phone:404-420-0116
Practice Address - Fax:404-420-0117
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021754207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000203002DMedicaid
GA5729084OtherAETNA PROVIDER NUMBER
GA11BDBCVMedicare ID - Type Unspecified
GAD40516Medicare UPIN