MEDICARE: MARK D WALSH

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	261QP2300X	Primary Care Clinic/Center		SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20774	OTHER	SC	LICENSE

General Provider Information

NPI Number	:	1912329889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK D WALSH

Provider Business Mailing Address
First Line	:	7611 HIGHWAY 76
Second Line	:	SUITE C
City	:	PENDLETON
State	:	SC
Zip	:	29670-9162
Country	:	US
Telephone Number	:	864-546-5570
Fax Number	:	864-546-5571

Provider Business Practice Location Address
First Line	:	7611 HIGHWAY 76
Second Line	:	SUITE C
City	:	PENDLETON
State	:	SC
Zip	:	29670-9162
Country	:	US
Telephone Number	:	864-546-5570
Fax Number	:	864-546-5571

Authorized Official
Title or Position	:	M.D. AND CEO
Name	:	DR. MARK D WALSH
Credential	:	MD
Telephone Number	:	864-653-0163

Provider Enumeration Date	:	01/13/2014
Last Update Date	:	01/13/2014

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