Healthcare Provider Details

I. General information

NPI: 1871507913
Provider Name (Legal Business Name): MARK D ROBERTS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 E HIGHWAY 76 SUITE 4
MULLINS SC
29574-6037
US

IV. Provider business mailing address

2845 E HIGHWAY 76 SUITE 4
MULLINS SC
29574-6037
US

V. Phone/Fax

Practice location:
  • Phone: 843-431-2720
  • Fax: 843-431-2726
Mailing address:
  • Phone: 843-431-2720
  • Fax: 843-431-2726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28818
License Number StateSC

VII. Legacy identifiers

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

# 1
IdentifierGP5462
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerMEDICAID GROUP
# 2
Identifier288183
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 3
IdentifierRHC538
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer
# 4
IdentifierGP0861
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: