=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962476192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK L. GRAVLEE, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11685 ALPHARETTA HWY SUITE 180
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-667-4991
-----------------------------------------------------
Fax | 770-667-4994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11685 ALPHARETTA HWY SUITE 180
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-4913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-667-4991
-----------------------------------------------------
Fax | 770-667-4994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK L. GRAVLEE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 770-667-4991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 34355
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------