Healthcare Provider Details

I. General information

NPI: 1164478848
Provider Name (Legal Business Name): MARK C BECKNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOUNT ZION PKWY KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER
JONESBORO GA
30236-2500
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-603-3614
  • Fax:
Mailing address:
  • Phone: 404-364-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: