Provider Demographics
NPI:1063607828
Name:MARK BYRON MD PC
Entity type:Organization
Organization Name:MARK BYRON MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BYRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-427-8033
Mailing Address - Street 1:162 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0101
Mailing Address - Country:US
Mailing Address - Phone:912-427-8033
Mailing Address - Fax:912-427-7565
Practice Address - Street 1:162 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0101
Practice Address - Country:US
Practice Address - Phone:912-427-8033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK BYRON MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-13
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047579261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 4653OtherMEDICARE GROUP NUMBER
GA00833599BMedicaid
GAE95715Medicare UPIN
GAGRP 4653Medicare PIN