Provider Demographics
NPI:1912931031
Name:MACK, JOSEPH A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
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 1:54 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769-2649
Mailing Address - Country:US
Mailing Address - Phone:207-762-6027
Mailing Address - Fax:
Practice Address - Street 1:49 2ND ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-2637
Practice Address - Country:US
Practice Address - Phone:207-762-4641
Practice Address - Fax:207-762-3336
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME013912174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME012223OtherANTHEM BC/BS
ME277470099Medicaid
300044777OtherRR MEDICARE
ME277470099Medicaid
ME012223OtherANTHEM BC/BS