1104377613 NPI number — DAVID A SACK MD A PROFESSIONAL MEDICAL CORPORATION

Table of content: (NPI 1104377613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104377613 NPI number — DAVID A SACK MD A PROFESSIONAL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID A SACK MD A PROFESSIONAL MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1104377613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 671387
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-1387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-567-7282
Provider Business Mailing Address Fax Number:
615-261-8912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20786 COOL OAK WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALIBU
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90265-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-235-2337
Provider Business Practice Location Address Fax Number:
310-943-0438
Provider Enumeration Date:
10/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MAPLESDEN
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
SR DIRECTOR RCM
Authorized Official Telephone Number:
615-540-3708

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0802X , with the licence number: 20A13416 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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