Basic Information
| Provider Information | |||||||||
| NPI: | 1578554606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUTHERLAND | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3686 | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284060686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104421100 | ||||||||
| FaxNumber: | 9104421199 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104421100 | ||||||||
| FaxNumber: | 9104421199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 06/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2006-00273 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2054049C | 01 | NC | MEDICARE PTAN | OTHER | 2054049 | 01 | NC | MEDICARE ID | OTHER | 5903826 | 05 | NC | MEDICAID | 2054049E | 01 | NC | MEDICARE PTAN | OTHER | P00843366 | 01 | NC | MEDICARE RAILROAD | OTHER |