MEDICARE: MARK C PETTUS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	28214	SC

General Provider Information

NPI Number	:	1528055209
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK C PETTUS M.D.

Provider Business Mailing Address
First Line	:	138 PATRICIA AVE
Second Line	:
City	:	DALTON
State	:	MA
Zip	:	01226-2045
Country	:	US
Telephone Number	:	413-684-2305
Fax Number	:

Provider Business Practice Location Address
First Line	:	3578 TOOMER KILN CIR
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29466-9260
Country	:	US
Telephone Number	:	843-884-4810
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	07/08/2007

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