Basic Information
| Provider Information | |||||||||
| NPI: | 1003000936 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STELLINGWORTH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 MEDICAL PARK DR STE 301 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295504779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433835978 | ||||||||
| FaxNumber: | 8433835977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0001X | 36377 | SC | N | 207RC0000X | 024969 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 36377 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | TL36377 | 01 | SC | MEDICAL LICENSE | OTHER | 024969 | 01 | LA | MEDICAL LICENSE | OTHER | 363779 | 05 | SC | MEDICAID |