1275522625 NPI number — DR. JONATHAN EBERHARD MACK M.D.

Table of content: TEDDY WISEMAN (NPI 1821987413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275522625 NPI number — DR. JONATHAN EBERHARD MACK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACK
Provider First Name:
JONATHAN
Provider Middle Name:
EBERHARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1275522625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
185 QUEEN CITY AVE
Provider Second Line Business Mailing Address:
ELLIOT ORTHOPAEDIC SURGERY SPECIALISTS
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03101-7100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-625-1655
Provider Business Mailing Address Fax Number:
603-626-4686

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 QUEEN CITY AVE
Provider Second Line Business Practice Location Address:
ELLIOT ORTHOPAEDIC SURGERY SPECIALISTS
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03101-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-625-1655
Provider Business Practice Location Address Fax Number:
603-626-4686
Provider Enumeration Date:
10/18/2005

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: 207XX0005X , with the licence number:  33787 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 50942 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 34952800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".