Healthcare Provider Details

I. General information

NPI: 1104825637
Provider Name (Legal Business Name): MARK GARY BUCHANAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 TOBIAS GADSON BLVD SUITE 201
CHARLESTON SC
29407-4707
US

IV. Provider business mailing address

2687 LAKE PARK DR
N CHARLESTON SC
29406-9100
US

V. Phone/Fax

Practice location:
  • Phone: 843-556-7060
  • Fax: 843-556-9960
Mailing address:
  • Phone: 843-572-0097
  • Fax: 843-725-3118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number019842
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: