Provider Demographics
NPI:1881169514
Name:MACK PEDIATRICS PLLC
Entity type:Organization
Organization Name:MACK PEDIATRICS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILI
Authorized Official - Middle Name:RACHELE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-825-3600
Mailing Address - Street 1:3721 LYNN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3855
Mailing Address - Country:US
Mailing Address - Phone:919-825-3600
Mailing Address - Fax:984-200-6001
Practice Address - Street 1:3721 LYNN RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-3855
Practice Address - Country:US
Practice Address - Phone:919-825-3600
Practice Address - Fax:984-200-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34D2157235OtherCLIA LABORATORY PROGRAM