Basic Information
Provider Information
NPI: 1003000936
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: STELLINGWORTH
FirstName: MARK
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 06/25/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 06/25/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X024969LAN Allopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
207RA0001X36377SCY    

ID Information
IDTypeStateIssuerDescription
TL3637701SCMEDICAL LICENSEOTHER
02496901LAMEDICAL LICENSEOTHER
36377905SC MEDICAID


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