Basic Information
| Provider Information | |||||||||
| NPI: | 1124227459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUGATE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 CITICO AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236972000 | ||||||||
| FaxNumber: | 4236972118 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 CITICO AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374041127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236972000 | ||||||||
| FaxNumber: | 4236972320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD44206 | TN | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 44206 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00741318 | 01 | RR MEDICARE | OTHER | 4230402 | 01 | TN | BCBS | OTHER | 1515384 | 05 | TN | MEDICAID | 163534 | 05 | AL | MEDICAID | 540820812A | 05 | GA | MEDICAID |