MEDICARE: DR. MARK COOPER STOVROFF 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	2086S0120X	Pediatric Surgery Physician	037088	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750380689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK COOPER STOVROFF M.D.

Provider Business Mailing Address
First Line	:	755 MOUNT VERNON HWY NE
Second Line	:	SUITE 460
City	:	ATLANTA
State	:	GA
Zip	:	30328-4274
Country	:	US
Telephone Number	:	404-252-7900
Fax Number	:	404-252-7905

Provider Business Practice Location Address
First Line	:	755 MOUNT VERNON HWY NE
Second Line	:	SUITE 460
City	:	ATLANTA
State	:	GA
Zip	:	30328-4274
Country	:	US
Telephone Number	:	404-252-7900
Fax Number	:	404-252-7905

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	10/03/2012

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