Provider Demographics
NPI:1184618019
Name:MACK, EMILI RACHELE (MD)
Entity type:Individual
Prefix:DR
First Name:EMILI
Middle Name:RACHELE
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 1:3721 LYNN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3855
Mailing Address - Country:US
Mailing Address - Phone:919-825-3600
Mailing Address - Fax:984-200-6001
Practice Address - Street 1:3721 LYNN RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-3855
Practice Address - Country:US
Practice Address - Phone:919-825-3600
Practice Address - Fax:984-200-6001
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2005-01260OtherSTATE MEDICAL LICENSE
NC5902210Medicaid
BM9475561OtherDEA