1891788782 NPI number — DR. AIMAR P MACK MD

Table of content: DR. AIMAR P MACK MD (NPI 1891788782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891788782 NPI number — DR. AIMAR P MACK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACK
Provider First Name:
AIMAR
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891788782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29528-2180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-234-9700
Provider Business Mailing Address Fax Number:
843-234-6990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2376 CYPRESS CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-8994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-234-9700
Provider Business Practice Location Address Fax Number:
843-234-6896
Provider Enumeration Date:
08/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  MD 28556 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP4505 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89137Y6 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 285569 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7844 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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