Basic Information
| Provider Information | |||||||||
| NPI: | 1366406407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1730 | ||||||||
| Address2: | |||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922701058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605682684 | ||||||||
| FaxNumber: | 7608372263 | ||||||||
| Practice Location | |||||||||
| Address1: | 39000 BOB HOPE DR | ||||||||
| Address2: | HARRY & DIANE RINKER BUILDING | ||||||||
| City: | RANCHO MIRAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922703221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605682684 | ||||||||
| FaxNumber: | 7608372263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | C50355 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | C50355 | 01 | CA | CA MEDICAL LICENSE | OTHER |