Side Mitchell Mack Jr., PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

0010-00323 Issued in NC

Practice address

1309 Lees Chapel Rd
Greensboro, NC 27455-2601

Phone

(336) 286-5505

Fax

(336) 288-2900

NPI assigned

May 16, 2006

Last updated

Feb 1, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in NC

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2005

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Carolina Medicorp Enterprises LLCGroup PAC ID 0648174904, 184 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: smack857105@direct.novanthealth.org

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Carolina Medicorp Enterprises, LLC

  dba Novant Health GoHealth Urgent Care

  • Urgent Care Clinic/Center
  • Charlotte, NC
  • NPI 1760950646
  Medicare reassignment Care Compare group
• Generations Family Practice, PA

  • Family Medicine Physician
  • Cary, NC
  • NPI 1407902059
  Medicare reassignment
• Carolina Medicorp Enterprises, LLC

  dba Novant Health GoHealth Urgent Care

  • Urgent Care Clinic/Center
  • Asheville, NC
  • NPI 1235014796
  NPD
• Carolina Medicorp Enterprises, LLC

  dba Novant Health GoHealth Urgent Care

  • Urgent Care Clinic/Center
  • Huntersville, NC
  • NPI 1972488427
  NPD
• Generations Family Practice, PA

  dba Triad Internal Medicine

  • Internal Medicine Physician
  • Asheboro, NC
  • NPI 1043894504
  NPD
• Wake Forest University Health Sciences

  • Multi-Specialty Clinic/Center
  • Winston Salem, NC
  • NPI 1003803032
  NPD (past)
• Wake Forest University Health Sciences

  • Clinic/Center
  • Greensboro, NC
  • NPI 1194964379
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147737600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643673600000",
    "number": "1740232966",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1021 DARRINGTON DR STE 101",
            "city": "CARY",
            "state": "NC",
            "postal_code": "275138158",
            "telephone_number": "919-852-3999",
            "fax_number": "919-378-9114"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1309 LEES CHAPEL RD",
            "city": "GREENSBORO",
            "state": "NC",
            "postal_code": "274552601",
            "telephone_number": "336-286-5505",
            "fax_number": "336-288-2900"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "794 S Main St Ste B",
            "address_purpose": "LOCATION",
            "city": "Kernersville",
            "state": "NC",
            "postal_code": "272844074",
            "country_code": "US",
            "telephone_number": "336-904-2317",
            "fax_number": "336-443-6030",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1200 N Elm St",
            "address_purpose": "LOCATION",
            "city": "Greensboro",
            "state": "NC",
            "postal_code": "274011004",
            "country_code": "US",
            "telephone_number": "336-716-2255",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MACK",
        "first_name": "SIDE",
        "middle_name": "MITCHELL",
        "name_suffix": "Jr.",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-16",
        "last_updated": "2022-02-01",
        "certification_date": "2022-02-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "1000323",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-00323",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1740232966",
            "state": "NC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "smack857105@direct.novanthealth.org",
            "affiliation": "N",
            "address_1": "794 S Main St Ste B",
            "city": "Kernersville",
            "state": "NC",
            "country_code": "US",
            "postal_code": "272844074",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Kendall Austin Macdonald, HEARING INSTRUMENT S
• Julie Harding Lucas Machen, M.D.
• Irene Nyakenyanya Machuki, NP
• Arica L Mack, NP
• Debra Cobb Mack
• Brian James Mackenzie, M.D.
• Cory Mackenzie
• Lisbeth Mackenzie, LCAS-A, CSAPC
• Theresa Ann Mackey, LCAS-A
• Stephen Barry Mackler, DDS,MS

• Physician Assistant in Greensboro, NC
• Providers in Greensboro, NC by specialty
• Physician Assistant in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.