Provider Demographics
NPI:1306942115
Name:GRAVLEE, MARK L (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:GRAVLEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2500 HOSPITAL BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4918
Mailing Address - Country:US
Mailing Address - Phone:470-956-4560
Mailing Address - Fax:770-475-8968
Practice Address - Street 1:2500 HOSPITAL BOULEVARD
Practice Address - Street 2:SUITE 420
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4919
Practice Address - Country:US
Practice Address - Phone:770-410-4661
Practice Address - Fax:770-410-4664
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2019-10-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA034355208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000454902DMedicaid
GA000454902EMedicaid
GA000454902EMedicaid