Provider Demographics
NPI:1548265689
Name:MACK, THOMAS J (DPM)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:MACK
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:21041 W SNOWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-6413
Mailing Address - Country:US
Mailing Address - Phone:630-390-8360
Mailing Address - Fax:
Practice Address - Street 1:6721 WEST 40TH STREET
Practice Address - Street 2:
Practice Address - City:STICKNEY
Practice Address - State:IL
Practice Address - Zip Code:60402-4171
Practice Address - Country:US
Practice Address - Phone:708-387-0633
Practice Address - Fax:708-387-0638
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL016-003-689213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003689Medicaid
IL016003689Medicaid