Healthcare Provider Details

I. General information

NPI: 1093944696
Provider Name (Legal Business Name): MARK MCCOMBS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2009
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BAY PARK DR
OREGON OH
43616-4920
US

IV. Provider business mailing address

PO BOX 633390
CINCINNATI OH
45263-3390
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-7900
  • Fax:
Mailing address:
  • Phone: 800-594-1876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50000205
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: