=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861464281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK TULLOS MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 W KINGSHIGHWAY STE 13
-----------------------------------------------------
City | PARAGOULD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-239-5916
-----------------------------------------------------
Fax | 870-239-5916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 W KINGSHIGHWAY STE 13
-----------------------------------------------------
City | PARAGOULD
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-239-5916
-----------------------------------------------------
Fax | 870-239-5916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK A TULLOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 870-239-5916
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | E3870
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------