MEDICARE: MISHIE MACK MANAGEMENT, INCORPORATED

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
1	208100000X	Physical Medicine & Rehabilitation Physician	I04412	TX

General Provider Information

NPI Number	:	1821320219
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISHIE MACK MANAGEMENT, INCORPORATED

Provider Business Mailing Address
First Line	:	2015 ENGELMOHR ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-3805
Country	:	US
Telephone Number	:	713-791-9539
Fax Number	:	713-791-9539

Provider Business Practice Location Address
First Line	:	2015 ENGELMOHR ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-3805
Country	:	US
Telephone Number	:	713-791-9539
Fax Number	:	713-791-9539

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MISHIE I CRAFT
Credential	:
Telephone Number	:	713-791-9539

Provider Enumeration Date	:	02/09/2010
Last Update Date	:	02/09/2010

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