Healthcare Provider Details

I. General information

NPI: 1730101254
Provider Name (Legal Business Name): VICKI LYNN MACK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N ENOLA DR SUITE 101
ENOLA PA
17025-2500
US

IV. Provider business mailing address

125 N ENOLA DR SUITE 101
ENOLA PA
17025-2500
US

V. Phone/Fax

Practice location:
  • Phone: 717-732-7171
  • Fax: 717-732-8872
Mailing address:
  • Phone: 717-732-7171
  • Fax: 717-732-8872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD067040L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0017468620001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: