Healthcare Provider Details

I. General information

NPI: 1851410617
Provider Name (Legal Business Name): TERRI LYNNE MACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MACK AVE
DETROIT MI
48201-2136
US

IV. Provider business mailing address

6858 PLAINVIEW ST
YPSILANTI MI
48197-1056
US

V. Phone/Fax

Practice location:
  • Phone: 313-578-5031
  • Fax: 313-578-6391
Mailing address:
  • Phone: 734-485-8055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301081963
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: