Healthcare Provider Details

I. General information

NPI: 1114075736
Provider Name (Legal Business Name): MR. JOSEPH MACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OLD WEST CHESTER PIKE
HAVERTOWN PA
19083-2712
US

IV. Provider business mailing address

1600 GARRETT RD APT. F312
UPPER DARBY PA
19082-4472
US

V. Phone/Fax

Practice location:
  • Phone: 484-454-8700
  • Fax: 484-454-8710
Mailing address:
  • Phone: 484-454-8700
  • Fax: 484-454-8710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPC004107
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: