MEDICARE: DR. MARK STEPHEN DENNIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	019030	LA
2	208VP0014X	Interventional Pain Medicine Physician	019030	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00249171	OTHER	LA	RR MEDICARE

General Provider Information

NPI Number	:	1801866215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK STEPHEN DENNIS M.D.

Provider Business Mailing Address
First Line	:	235 SAINT ANN DR
Second Line	:	SUITE 2
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3396
Country	:	US
Telephone Number	:	985-727-7275
Fax Number	:	985-727-7915

Provider Business Practice Location Address
First Line	:	235 SAINT ANN DR
Second Line	:	SUITE 2
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3396
Country	:	US
Telephone Number	:	985-727-7275
Fax Number	:	985-727-7915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	09/25/2008

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