Healthcare Provider Details

I. General information

NPI: 1548265689
Provider Name (Legal Business Name): THOMAS J MACK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6721 WEST 40TH STREET
STICKNEY IL
60402-4171
US

IV. Provider business mailing address

21041 W SNOWBERRY LN
PLAINFIELD IL
60544-6413
US

V. Phone/Fax

Practice location:
  • Phone: 708-387-0633
  • Fax: 708-387-0638
Mailing address:
  • Phone: 630-390-8360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016-003-689
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: