Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC003097L | PA |
NPI | 1689644726 |
---|---|
Provider Name | Dr. Thomas C Mack |
First Address | Corry, PA 16407-1558 |
Second Address | Corry, PA 16407-1558 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
155842 | HEALTH AMERICA (01) | PA |
456615 | BLUE CROSS/BLUE SHIELD (01) | PA |
T72491 | (02) | PA |