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General NPI Number Information
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NPI Number | 1467542399
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Entity Type | Organization
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Legal Business Name | BLACK HILLS FAMILY PRACTICE CLINIC PS
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 10/13/2014
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Provider Practice Location Address
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Address Line | 332 S BIRCH ST
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City | MCCLEARY
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State | WA
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Zip | 98557-9522
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Country | US
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Telephone | 360-495-3475
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 68
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City | MCCLEARY
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State | WA
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Zip | 98557-0068
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Country | US
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Telephone | 360-495-3475
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDWARD R MACKE
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Credential | MD
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Telephone | 360-495-3475
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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