Healthcare Provider Details

I. General information

NPI: 1962645226
Provider Name (Legal Business Name): MACK OCCUPATIONAL HEALTH SERVICES SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2009
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N528 FAIRLAND ISLAND
MENOMINEE MI
49858
US

IV. Provider business mailing address

2643 LIBAL STREET
GREEN BAY WI
54301
US

V. Phone/Fax

Practice location:
  • Phone: 906-424-4089
  • Fax:
Mailing address:
  • Phone: 920-435-1604
  • Fax: 920-435-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS V. MACK
Title or Position: CEO
Credential: M.D.
Phone: 906-424-4089