Provider Demographics
NPI:1457317588
Name:MACK, RICHARD HENRY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HENRY
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 1:515 FAIRMOUNT AVE
Mailing Address - Street 2:CREDENTIALING DEPARTMEN
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-5466
Mailing Address - Country:US
Mailing Address - Phone:410-494-1324
Mailing Address - Fax:410-494-1361
Practice Address - Street 1:515 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 530
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-5466
Practice Address - Country:US
Practice Address - Phone:410-494-1389
Practice Address - Fax:410-494-1386
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD07902207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD308331400Medicaid
MD200017416Medicare PIN
MDD76762Medicare UPIN
MDX774Medicare PIN