Provider Demographics
NPI:1952395709
Name:PACK, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:PACK
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:PO BOX 603898
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3898
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:805 PAMPLICO HWY STE A230
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6057
Practice Address - Country:US
Practice Address - Phone:843-669-1220
Practice Address - Fax:843-669-3725
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2021-03-05
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
KY28407208600000X
OH35074195P208600000X
SC35481208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC354814Medicaid
KY020049006Medicare PIN
SC354814Medicaid
F24531Medicare UPIN
KY0719901Medicare PIN