Healthcare Provider Details

I. General information

NPI: 1538172960
Provider Name (Legal Business Name): MARK A DEMOSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501C MEMORIAL DR EXT
GREER SC
29651
US

IV. Provider business mailing address

501C MEMORIAL DR EXT
GREER SC
29651
US

V. Phone/Fax

Practice location:
  • Phone: 864-877-1220
  • Fax: 864-877-7731
Mailing address:
  • Phone: 864-877-1220
  • Fax: 864-877-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20597
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier562212236
Identifier TypeOTHER
Identifier State
Identifier IssuerCHAMPUS
# 2
IdentifierGP2981
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: