Healthcare Provider Details

I. General information

NPI: 1578554606
Provider Name (Legal Business Name): MARK JOSEPH SUTHERLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

PO BOX 3686
WILMINGTON NC
28406-0686
US

V. Phone/Fax

Practice location:
  • Phone: 803-935-8538
  • Fax:
Mailing address:
  • Phone: 910-442-1100
  • Fax: 910-442-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2006-00273
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number92198
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: