Healthcare Provider Details

I. General information

NPI: 1740232966
Provider Name (Legal Business Name): SIDE MITCHELL MACK JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 LEES CHAPEL RD
GREENSBORO NC
27455-2601
US

IV. Provider business mailing address

1021 DARRINGTON DR STE 101
CARY NC
27513-8158
US

V. Phone/Fax

Practice location:
  • Phone: 336-286-5505
  • Fax: 336-288-2900
Mailing address:
  • Phone: 919-852-3999
  • Fax: 919-378-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1000323
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-00323
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: