Organization
BLACK HILLS FAMILY PRACTICE CLINIC PS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. EDWARD R MACKE MD (PRESIDENT)
(360) 495-3475
Entity
Organization
Contact information
Practice address
332 S BIRCH ST, MCCLEARY, WA 98557-9522
(360) 495-3475
Mailing address
PO BOX 68, MCCLEARY, WA 98557-0068
(360) 495-3475
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
008N
BLUE CROSS
—
01
—
1009515
COMMUNITY H
—
05
—
1252402
—
WA
01
—
15628
SLI
—
01
—
75243
UNIFORM
—
01
—
8009961
AETNA
—
01
—
95958
PACIFIC CARE
—
01
—
A002
TRICARE
—
01
—
MA8267
REGENCE
—
01
—
QMXPR0055448
MOLINA
—
Enumeration date
10/13/2006
Last updated
10/13/2014
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