Healthcare Provider Details

I. General information

NPI: 1255338547
Provider Name (Legal Business Name): MARK L WITHROW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W STONE DR STE 5D
KINGSPORT TN
37660-3365
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-247-7500
  • Fax: 423-247-7556
Mailing address:
  • Phone: 423-857-2093
  • Fax: 423-390-3340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101274055
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD025903
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101274055
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25903
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: