Healthcare Provider Details

I. General information

NPI: 1740450220
Provider Name (Legal Business Name): MARK AINSLEY INNIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 HIGH ST
PORTSMOUTH VA
23707-3236
US

IV. Provider business mailing address

1431 CENTERPOINT BLVD SUITE 100
KNOXVILLE TN
37932-1984
US

V. Phone/Fax

Practice location:
  • Phone: 757-398-2200
  • Fax: 757-398-2359
Mailing address:
  • Phone: 865-985-7012
  • Fax: 865-985-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number248590
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101243430
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: