Healthcare Provider Details

I. General information

NPI: 1063607828
Provider Name (Legal Business Name): MARK BYRON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 MEMORIAL DR
JESUP GA
31545-0101
US

IV. Provider business mailing address

162 MEMORIAL DR
JESUP GA
31545-0101
US

V. Phone/Fax

Practice location:
  • Phone: 912-427-8033
  • Fax:
Mailing address:
  • Phone: 912-427-8033
  • Fax: 912-427-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number047579
License Number StateGA

VIII. Authorized Official

Name: MARK DANIEL BYRON
Title or Position: MD OWNER
Credential: M.D.
Phone: 912-427-8033