Provider Demographics
NPI:1356542492
Name:MARK S. PACK, MD, PSC
Entity type:Organization
Organization Name:MARK S. PACK, MD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-833-9556
Mailing Address - Street 1:1101 SAINT CHRISTOPHER DR
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-7087
Mailing Address - Country:US
Mailing Address - Phone:606-833-9556
Mailing Address - Fax:
Practice Address - Street 1:1101 SAINT CHRISTOPHER DR
Practice Address - Street 2:SUITE 320
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7087
Practice Address - Country:US
Practice Address - Phone:606-833-9556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28407208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7199Medicare ID - Type Unspecified
F24531Medicare UPIN