=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356542492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK S. PACK, MD, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2007
-----------------------------------------------------
Last Update Date | 04/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 SAINT CHRISTOPHER DR SUITE 320
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-7087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-833-9556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1101 SAINT CHRISTOPHER DR SUITE 320
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-7087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-833-9556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK S. PACK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 606-833-9556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 28407
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------