Healthcare Provider Details

I. General information

NPI: 1912329889
Provider Name (Legal Business Name): MARK D WALSH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2014
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7611 HIGHWAY 76 SUITE C
PENDLETON SC
29670-9162
US

IV. Provider business mailing address

7611 HIGHWAY 76 SUITE C
PENDLETON SC
29670-9162
US

V. Phone/Fax

Practice location:
  • Phone: 864-546-5570
  • Fax: 864-546-5571
Mailing address:
  • Phone: 864-546-5570
  • Fax: 864-546-5571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateSC

VIII. Authorized Official

Name: DR. MARK D WALSH
Title or Position: M.D. AND CEO
Credential: MD
Phone: 864-653-0163