Provider Demographics
NPI:1841289865
Name:JOAN M MACK RPT
Entity type:Organization
Organization Name:JOAN M MACK RPT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-374-2127
Mailing Address - Street 1:1574 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6120
Mailing Address - Country:US
Mailing Address - Phone:513-374-2127
Mailing Address - Fax:518-374-2142
Practice Address - Street 1:1574 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-6120
Practice Address - Country:US
Practice Address - Phone:513-374-2127
Practice Address - Fax:518-374-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0184495Medicaid