Basic Information
Provider Information | |||||||||
NPI: | 1487673232 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MACK | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | ROSE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOOMIS | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | ROSE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1523 GREENSBORO WAY | ||||||||
Address2: |   | ||||||||
City: | GRAYSON | ||||||||
State: | GA | ||||||||
PostalCode: | 300172907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7703162883 | ||||||||
FaxNumber: | 7709727332 | ||||||||
Practice Location | |||||||||
Address1: | 821 N COBB ST | ||||||||
Address2: |   | ||||||||
City: | MILLEDGEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310612343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4784543795 | ||||||||
FaxNumber: | 4784543969 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 039858 | GA | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00653001U | 05 | GA |   | MEDICAID |