MEDICARE: KAMRYN ALICE MACK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601009636	MI

General Provider Information

NPI Number	:	1619445228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAMRYN ALICE MACK PA-C

Provider Business Mailing Address
First Line	:	22255 GREENFIELD RD STE 400
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3734
Country	:	US
Telephone Number	:	248-849-4880
Fax Number	:	248-849-4881

Provider Business Practice Location Address
First Line	:	22255 GREENFIELD RD STE 400
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48075-3734
Country	:	US
Telephone Number	:	248-849-4880
Fax Number	:	248-849-4881

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	01/06/2022

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