Provider Demographics
NPI:1861612814
Name:MACK, BRIGID (MD)
Entity type:Individual
Prefix:
First Name:BRIGID
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:391 MYRTLE AVE STE 4A
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3797
Practice Address - Country:US
Practice Address - Phone:518-207-2273
Practice Address - Fax:518-207-2293
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY249141207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03015689Medicaid
NYJ400006761Medicare PIN
NY03015689Medicaid