=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487673232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH ROSE MACK M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 N COBB ST
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-454-3795
-----------------------------------------------------
Fax | 478-454-3969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1523 GREENSBORO WAY
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30017-2907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-316-2883
-----------------------------------------------------
Fax | 770-972-7332
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 039858
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------