Healthcare Provider Details

I. General information

NPI: 1467542399
Provider Name (Legal Business Name): BLACK HILLS FAMILY PRACTICE CLINIC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 S BIRCH ST
MCCLEARY WA
98557-9522
US

IV. Provider business mailing address

PO BOX 68
MCCLEARY WA
98557-0068
US

V. Phone/Fax

Practice location:
  • Phone: 360-495-3475
  • Fax:
Mailing address:
  • Phone: 360-495-3475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD R MACKE
Title or Position: PRESIDENT
Credential: MD
Phone: 360-495-3475