Provider Demographics
NPI:1689644726
Name:MACK, THOMAS C (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:MACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W SMITH ST
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-1558
Mailing Address - Country:US
Mailing Address - Phone:814-665-1032
Mailing Address - Fax:814-665-2225
Practice Address - Street 1:116 W SMITH ST
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-1558
Practice Address - Country:US
Practice Address - Phone:814-665-1032
Practice Address - Fax:814-665-2225
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003097L111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA155842OtherHEALTH AMERICA
PA456615OtherBLUE CROSS/BLUE SHIELD
PA456615Medicare ID - Type Unspecified
PA456615OtherBLUE CROSS/BLUE SHIELD