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NPI Code Detail

MEDICARE: SIDE MITCHELL MACK JR. PA

MEDICARE: SIDE MITCHELL MACK JR. PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant1000323NC
2363A00000XPhysician Assistant0010-00323NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1740232966
Entity Type Code : Individual
Provider Name (Legal Business Name) : SIDE MITCHELL MACK JR. PA
Provider Business Mailing Address
First Line : 1021 DARRINGTON DR STE 101
Second Line :
City : CARY
State : NC
Zip : 27513-8158
Country : US
Telephone Number : 919-852-3999
Fax Number : 919-378-9114
Provider Business Practice Location Address
First Line : 1309 LEES CHAPEL RD
Second Line :
City : GREENSBORO
State : NC
Zip : 27455-2601
Country : US
Telephone Number : 336-286-5505
Fax Number : 336-288-2900
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/16/2006
Last Update Date : 02/01/2022

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Directions to “ SIDE MITCHELL MACK JR. PA” Practice Location

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