Active NPI
Paul Jeffrey Mack, CHTP, ED.D, MS, BA
- Specialist
- Saint Louis, MO
National Provider Identifier
1780740563
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Specialist
- License
- 2504
- Practice address
- 1015 McCausland Ave
Saint Louis, MO 63117-1924 - Phone
- (314) 781-5050
- NPI assigned
- Dec 28, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Specialist | 174400000X | 2504 | CO | Primary |
Addresses
Primary practice location
1015 McCausland Ave
Saint Louis, MO 63117-1924
Mailing address
2960 Milton Blvd
Saint Louis, MO 63104-1636
Phone (314) 497-5247
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Bachelor of Arts, Master of Science
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2504 | CO | MD | Specialist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1167264000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1780740563",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2960 MILTON BLVD",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631041636",
"telephone_number": "314-497-5247"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1015 MCCAUSLAND AVE",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631171924",
"telephone_number": "314-781-5050"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MACK",
"first_name": "PAUL",
"middle_name": "JEFFREY",
"credential": "CHTP, ED.D, MS, BA",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-12-28",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "174400000X",
"taxonomy_group": "",
"desc": "Specialist",
"state": "CO",
"license": "2504",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Louis, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.