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General NPI Number Information
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NPI Number | 1972411734
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Entity Type | Organization
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Legal Business Name | DR MACK FUNCTIONAL & FAMILY MEDICINE PC
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Dates
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Enumeration Date | 08/31/2026
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Last Update Date | 08/31/2026
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Provider Practice Location Address
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Address Line | 40 ROUTE 46
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City | PINE BROOK
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State | NJ
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Zip | 07058-9387
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Country | US
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Telephone | 914-588-4454
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Fax |
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Provider Business Mailing Address
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Address Line | 40 ROUTE 46
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City | PINE BROOK
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State | NJ
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Zip | 07058-9387
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Country | US
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Telephone | 914-588-4454
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. MACK LEE SULLIVAN
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Credential | MD
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Telephone | 914-395-3691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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