Basic Information
| Provider Information | |||||||||
| NPI: | 1891788782 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACK | ||||||||
| FirstName: | AIMAR | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2180 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295282180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432349700 | ||||||||
| FaxNumber: | 8432346990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2376 CYPRESS CIRCLE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432349700 | ||||||||
| FaxNumber: | 8432346896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | MD 28556 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | GP4505 | 05 | SC | MEDICAID | 89137Y6 | 05 | NC | MEDICAID | 285569 | 05 | SC | MEDICAID | 7844 | 01 | SC | MEDICARE PTAN | OTHER |