Basic Information
| Provider Information | |||||||||
| NPI: | 1457445892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | TERRANCE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 586397533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015676130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 HIGHWAY 12 | ||||||||
| Address2: | |||||||||
| City: | HETTINGER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015674561 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | 3393 | ND | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0553685 | 05 | IA | MEDICAID | 10777 | 01 | ND BLUE CROSS | OTHER | 27025 | 01 | SIOUX VALLEY | OTHER | 4999831 | 01 | SD WELLMARK | OTHER | 123993 | 01 | WORKERS COMP | OTHER | 45034068812 | 05 | NE | MEDICAID | 7776040 | 05 | SD | MEDICAID | 12565 | 05 | ND | MEDICAID |